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1920 ^^njk^ 


This work is intended to be a handbook for those who 
wish to understand something of the machinery for 
the conduct of work for Maternity and Child Welfare. 

It makes no effort to be a comprehensive text-book 
on either Local Government or Child Hygiene in any of 
its branches. These matters form part of the frame- 
work of the book, but the aim has been to give only 
such aspects of both these subjects as appeared neces- 
sary for an intelligent understanding of the work 
under consideration. 

The book has been written under pressure of other 
work, which has rendered much revision of the origiual 
manuscript impossible for lack of time. The subject- 
matter of the book has been dealt with for some time 
past in lectures to students of the Household and 
Social Science Department of King's College for Women. 
Now that the College is undertaking the training of 
health visitors under the recent Board of Education 
Regulations, a short text-book on matters with which 
all health visitors should be familiar seemed opportune, 
and the request to write a handbook served to supply 
the necessary stimulus. The opinions expressed have 
been formed primarily as a result of four years' work 
practically all over the country, when serving as Medical 
Inspector for Child Welfare under the Local Govern- 
ment Board. 

It is believed that record has been made of opposing 


views whenever there is known to be a definite school 
of thought of opposite tendencies. 

It is usual, however, in life to find that the cause of 
divergence of views is due primarily to inadequacy of 
explanation. This arises especially in connection with 
Child Welfare work, when, for example, those with urban 
experience only, discuss matters with those working 
in rural districts. The conditions are so different in 
these areas as to justify apparently opposite views. 
When the district under discussion is specified, it will 
usually be found that any remaining difference of opinion 
is on unimportant matters only, or due to the fact that 
one side contemplates an ideal regardless of cost or 
feasibility, and the other envisages such development as 
may be capable of accomplishment under existing powers 
and conditions. 

No attempt has been made throughout the book to 
deal with the work of the Poor Law Guardians, either 
under the Poor Law or under the Children Act of 1908. 
While theoretically, no doubt, many phases of their 
work fall under the general meaning of Child Welfare 
work, it is not included under what is ordinarily under- 
stood by this term. 

Further, it is probable that the whole Poor Law 
system will now be short-lived, and as Public Health 
workers are not closely concerned with its working as 
at present carried out, it appeared unnecessary to deal 
with it. 

The chapters on Local Government are inserted with 
the view of explaining certain points in the machinery, 
upon which information is not readily accessible. 

They are not intended to form a treatise on Local 
Govenmient as such. 

I am indebted to St. Katharine's Royal College at 
Poplar, and to Dr. Harold Waller their Medical Officer, 
for permission to print samples of their record cards. 
To the Controller of His Majesty's Stationery Office for 


permission to reproduce the Act and Circulars which 
form the subject-matter of Appendices III., IV., V. (A) 
and (B), and VIII. The documents are not printed by 

Further, I desire to acknowledge with many thanks 
the permission given by the Medical Officers of Durham 
County, Hertfordshire, and Birmingham to reprint the 
subject-matter of Appendices VI. and VII. 

I am also greatly indebted to Mr. H. 0. Stutchbury, 
of the Ministry of Health, for kindly reading many of 
the chapters, especially those on Local Government, and 
for numerous valuable suggestions ; and to Dr. Major 
Greenwood, who was good enough to read over the 
chapter on Infant Mortality. 


March 1920. 



Preface . . . ' . . . v 


I. Introductory ..... 1 

II. On Notification of Births in Relation to 

Child Welfare .... 8 

III. The Work under the Notification of Births 

Acts . . . . . .16 

IV. The Relation of the Child Welfare Visitor 

to Charitable and Social Organisations . 27 

V. Points in the Arrangements and the Condi- 
tions of Work of an Infant Visitor . 30 

VI. The Child Welfare Cbntrb . . .38 

VII. The Centre (conti7iued) . . . .52 

VIII. The Centre (continued) . . .69 

IX. The Organisation of Child Welfare Work 

IN Urban Areas . . . .81 

X. The Combined Duties of a Visitor in the 
Different Local Authorities in Urban 
Areas . . . . .88 

XI. Child Welfare Work in County Areas . 91 

b ix 



XII. Thb Training of Health Visitors . . 101 

XIII. The Position of Voluntary Agencies in 

Child Welfare Work .110 

XIV. Other Phases op Child Welfare Work , 115 

XV. The Control of the Practice of Midwifery 125 

XVI. Pre-natal Work . .137 

XVII. Attendance at Birth and Maternity Nursing 147 

* XVIII. The Provision of Maternity Care by 

Institutions . . . . .159 

XIX. On the Present Provision op Midwives . 167 

^ XX. Infant Mortality . .176 

XXI. Notifiable Diseases in Relation to Mater- 
nity AND Child Welfare, with Notes on 
Measles and Whoopinq-Couoh . .188 

XXII. Local Government Areas . . 194 

XXIII. Local Government Authorities : their 

Powers and Duties .... 202 

XXIV. Notes on the Machinery op Local 

Authorities ..... 214 

XXV, The Sources of Money for Local Govern- 
ment PUBPOSES .... 222 

XXVI. The Future .230 



I. Sample Record Cards and Leaflets . . . 235 

II. Figures showing the Ailments among School 

Children 241 

i III. Maternity and Child Welfare Act, 1918, with 

Circulars 4 and 11 . . . .242 

IV. Circular by the Ministry of Health on the Training 

of Health Visitors . . . .263 

V. (A) Extracts from the Board of Education Regu- 
lations for Nursery Schools . . . 270 

(B) Ministry of Health Circular on Day Nurseries . 282 

VI. (A) Scheme for a Trained Midwifery Service in 

Durham County .... 288 

(B) Scheme of Payments and Pensions for Mid- 
wives in Hertford:shire . . . 294 

VII. Housing and Sanitary Conditions in Relation tu 

Mortality Rates in Bii-mingham . . 303 

VIII. Extracts from the Ministry of Health Circular on 

Measles and German Measles . , .316 




The rapid growth of the child welfare movement has 
tended to the concentration of attention on the activities 
of the movement, so that the causes which led to the 
movement, and the principles underlying it are some- 
times passed over by those engaged in the work. 

In common with the initial phases of other movements, 
the cry for improvement in the condition of infants and 
children was made by a few pioneers many years before 
a sufficient impetus had been given to the work to secure 
its public discussion. It is probable that these pioneers 
did not themselves appreciate the greatness of the work 
they felt constrained to begin. Different methods were 
used in the several different countries, but the primary 
cause of the effort was the same in all — namely, an 
attempt to reduce the number of deaths among infants. 
There is no reason to suppose that the death-rate among 
infants was higher at any time during the nineteenth 
century than it had been in earlier times — on the con- 
trary, such evidence as there is shows that in all prob- 
ability the number of children who survived and 
reached adult life, as compared with those that died, 
was considerably lower in the preceding centuries. 
The number of both births and deaths was almost 


certainly less during the last half -century than previously. 
! As civilisation progresses the value placed upon life is 
' increased, and a high death-rate comes to be regarded 
as a blot on the nation and produces efforts to bring about 
its reduction. A reduction in the number of births 
appears also to be a natural accompaniment of ad- 
vancing culture. 

The keeping of accurate registers of births and deaths 
is comparatively recent in this country, and it is prob- 
able that, apart from a few of the smaller and more 
advanced European countries, only Great Britain, 
France, and Germany possess records which may be 
regarded as sufficiently accurate for all practical pur- 
poses. Even for these countries the figures dealing with 
similar matters cannot be compared with one another, 
since the bases of their preparation are not necessarily 
the same. Speaking generally, there is a close relation- 
ship between the vitality of a nation and its rate of in- 
crease. The rate of increase is clearly determined by 
the excess of births over deaths. Where the excess 
becomes very small, it behoves a nation to take active 
steps to preserve its future. In France, for many years 
before the war, there had been no appreciable excess of 
births over deaths and the population had remained 
almost stationary, but with a tendency to decrease. 
In other countries where figures are obtainable there was 
still a large excess of births over deaths, but ths excess 
was diminishing fairly rapidly. 

It was necessary either that there should be a re- 
duction in the number of deaths or an increase in the 
number of births, or, in the opinion of some, both these 
changes should take place. The first efforts were made 
towards a reduction in the rate of mortality among 
infants. It is probable that many of those who took 
part in the beginning of the movement were^ actuated 
fully as much by philanthropic motives as by an appre- 
ciation of the need of the work. In France, however, 


the early efforts were a direct response on a small scale 
to a known need, and the same must be said of the 
similar efforts of local authorities in this country. 
The aim was the prevention of preventable deaths 
among infants. 

In England in the 'seventies and 'eightiesthe first efforts 
were directed to the visitation of infants in their homes. 
In France in the 'eighties, the movement commenced 
by encouraging breast-feeding among the mothers who 
were confined in a maternity hospital and by giving 
them suitable advice. The name of Professor Budin 
will always remain associated with this, the first infant 
consultation {consultation des nounrissons). The success 
achieved by this infant consultation led to the estab- 
lishment of similar organisations for artificially-fed 
babies, and, in addition to the advice, a supply of good 
milk was provided either free or at a small charge. 
These institutions were known as gouttes de lait. It 
should be noted that medical advice was given to the 
mother as to the way she should feed her child with the 
milk. The provision of food for the hungry makes a 
powerful appeal to most people, but, as will be shown, 
the provision of milk for infants, without instruction as 
to the method of using it, does not produce the satis- 
factory results which had been anticipated. 

Milk depots for the supply of milk, without, however, 
the medical advice, found some footing in this country. 
The first depot was opened at St. Helen's in 1889. Al- 
though certain of the depots opened rather later by 
Liverpool, Battersea, Lambeth, Leicester, and a few 
other boroughs are still open, for the most part they 
have been closed, or, as at St. Helen's, have become depots 
for the provision of dried milk when ordered by the 
medical officer of the infant consultation. (For further 
details see pp. 56 et seq.) 

Belgium started in yet another direction and opened 
schools for mothers. During the early years of the 


present century the movement, as represented by one 
or more of the above methods of work, spread into the 
western nations of Europe. The progress became very 
rapid about the year 1906 and after. In this country, 
the local authorities developed home visitation, aided 
by the Notification of Births Acts of 1907, and a con- 
siderable number of them opened centres for infant 
consultations. At first many of the centres which 
were started in different places were supported and 
managed by voluntary agencies, and some home visiting 
was also undertaken by them. It is almost a practice 
in this country for voluntary effort to take the first steps 
in any new branch of work, and the country usually re- 
frains from spending public money, either taxes or rates, 
upon experiments. As the movement has grown, the 
local authorities have continually taken over more of 
the work of the voluntary societies, wlio have either 
joined in with the official work of the district or have 
diverted their energies to new developments. 

During the last ten years the general movement has 
spread widely, until, at the present time, there is hardly 
a country, however primitive, that is not stirred by the 
need for improving the condition of its children. The 
experience gained has led to the continual introduction 
of fresh branches of work and of new methods. Organis- 
ations have been started and grown with almost in- 
credible rapidity until the varieties and complications 
of activities are almost bewildering. 

The development of home visitation and work at the 
centre, whether by infant consultations or by schools 
for mothers, showed that new branches of work must 
be opened up if satisfactory results were to be obtained. 
The home visiting without work at the centre was 
proved to be insufficient, and the work at the centre 
required close co-ordination with the home visitation. 
This is necessary in order that the medical officer may 
be cognisant of the home conditions on the one hand, 


and that the health visitor on the other hand may 
know the advice which should be given in carrying 
out her work in the home. The schools for mothers 
realised the need for medical advice in addition to their 
classes, and the infant consultations found it necessary 
to make arrangements for assistance for the mothers 
in regard to advice as to clothing and instruction in the 
care of infants generally. 

At the same time that the work for infants was de- 
veloping, the medical inspection of school children was 
introduced and its importance recognised almost at 
once. The inspection showed a deplorable condition 
of ill-health among children entering school, and 
brought into prominence the urgent need for super- 
vision of children in the early years of life. It was, how- 
ever, realised that care must be extended still further 
backwards and that many of the aihnents arising in 
young children before they attend school have their 
origin in defects of health diu"ing infancy, which again 
in many cases are due to ignorance on the part of the 
mother or to unsatisfactory environment of one kind or 
another. There can be no question that the work of 
school medical inspection has afforded a very powerful 
stimulus to the child welfare movement. 

Then, again, those concerned with the work soon dis- 
covered that if their efforts were to be effective it was 
not sufficient to deal with the child after birth. The 
care of the children before and at birth has been 
shown to be a most essential feature of the work, and 
this clearly involves the care of the mother. For some 
years past pre-natal work has been recognised as an 
essential feature of child welfare work. There are, 
however, certain inherent difficulties comiected with it 
which have prevented the rapid expansion of the work. 

Further, it has become increasingly evident that the 
care of the mother at the confinement is an immensely 
important factor in child welfare work. Such care 


brings the child welfare movement at once into close 
touch with those who are concerned in the practice 
of midwifery, and it is to be hoped that the co-opera- 
tion necessary to secure the most satisfactory con- 
ditions for the infant and its mother may form a 
leading feature in child welfare work in the immediate 

Investigations into the causes of infant mortality 
have shown the immense complexity of the problem 
of the prevention of infant deaths. The conditions 
of employment of the parent, the home conditions, 
general sanitation, feeding, etc., all play a part in the 
health of young children. 

The child welfare movement has also brought into 
prominence the need for further curative measures 
in many directions. At the present time there appears 
to be a distinct tendency for the child welfare move- 
ment to expand on the curative side of medicine. It is 
perhaps not unnatural that there should be this ten- 
dency in view of the large amount of ill-health for which 
at present inadequate provision is made. At the same 
time, it should never be forgotten that child welfare 
work is essentially preventive : its object is to preserve 
the health of healthy infants, and to give such advice 
as may assist the mother in bringing up her child so as 
to avoid all unnecessary ailments or disease. 

Preventive work is at all times more difficult, and in 
some ways less attractive than curative, but its im- 
portance can hardly be exaggerated : it is the essence 
of public health work. 

Child welfare work should, however, be linked up 
with curative measures, since all disease cannot be 
prevented, and adequate treatment is necessary to 
secure a return to health. The various activities and 
their relationship to other agencies will be considered 
fully under separate headings in subsequent chapters. 
It may safely be said that at the present time no 


country is so fully covered by organisations for child 
welfare as England and Wales, and in no other country 
have the State and the local authorities together 
produced such complete arrangements for carrying 
out improvements in the health of the children of the 

While much was being done before the war, under 
the pressure of that upheaval undreamed-of develop- 
ments have occurred. The country is still assimilating 
the lessons learned in the furnace, and the time to strike 
is when the iron is hot. It behoves us to increase our 
efforts, and to fill up the gaps in our organisations and 
in our knowledge. There is much ignorant talk and 
loose thinking on child welfare work in all its branches. 
It does not perhaps impede the progress of sound work, 
but, if only the energy thus employed were directed 
oa informed lines, it is impossible to say how greatly 
k might assist. 

Certain aspects of information have not been readily 
accessible hitherto. This book will be only one of 
many, but it is hoped that it may prove a slight addition 
to the literature upon the subject, and may at least aid 
the rising generation in their efforts to learn about the 
needs of their fellow- citizens. 


On Notification of Births in Relatiojt to 
Child Welfare 

The early workers in the cause of infant weliare found 
themselves face to face with a grave difficulty at the 
very commencement of their work. This difficulty 
lay in the absence of information as to the whereabouts 
of the infants who were to be the objects of assistance. 

The workers set before themselves the prevention of 
infant mortality by means of advice as to the care of the 
infant and the improvement in the general conditions 
of the home. 

There were two methods of finding the homes where 
babies had been recently born — the one by direct house- 
to-house visitation, and the other by applying to the 
Registrar of Births. 

Up to 1837 there had been registers of baptisms kept 
in the various churches and chapels, but these records 
were admittedly far from being complete. In this 
year the registration of all infants within forty-two 
days after their birth became obligatory on the parent. 

The Manchester and Salford Ladies' Health Society 
seems to have been the pioneer agency in child welfare 
work. The society was founded in the 'sixties by 
ladies who were impressed with the unhealthy con- 
ditions of the poorer homes. They did not themselves 
undertake the visiting, but employed other women to 
do this. These were untrained, but at that time there 
was little in the way of training which could be taken 

by women. The towns were divided into districts, and 



each worker visited in her own district. It was, how- 
ever, soon realised that the method of house-to-house 
visitation involved much loss of time and energy since 
in many houses there were no infants, and the society 
was concerned with infants only. 

After a while it was arranged that the Registrar 
of Births should supply to the society lists of the births 
registered in order to reduce the difficulty. The regis- 
tration is confidential, and special permission from^the 
Registrar-General was necessary to secure the informa- 
tion. Even then, however, it was found that in quite 
a number of cases the child had died, or its parents 
had removed from the neighbourhood before it was 
possible to visit. 

Some years later other towns in Lancashire appointed 
women who had been trained as sanitary inspectors 
to undertake similar work on similar lines. These 
women carried out much valuable work, but it was 
impossible to cope with the problem with any real 
effect, so long as the whereabouts of the children were 
not more accurately known. 

It was realised that a more effective method of dealing 
with the position must be introduced, and that some- 
thing must be done to secure notification of the homes 
where infants had been born at an earlier period of their 
lives tlian that compulsory for registration. 

The first effort at notification of births seems to have 
been made in Salford in 1889. In that year the medical 
officer of health asked all the mid wives practising 
in the district to notify to him at once the names and 
addresses of the women they attended. This informa- 
tion was then passed on to the visitor for the district. 
In 1906 Huddersfield obtained parliamentary powers 
for the compulsory notification of births to the medical 
officer of health. 

This was followed in 1907 by the passing of the first 
Notification of Births Act, introduced by Lord Robert 


Cecil as a private Bill. The measure was taken over 
by the Government of the day and passed into law 
under the guidance of Mr. John Burns, then President 
of the Local Government Board. 

This Act was an adoptive Act, and must be distin- 
guished from the Notification of Births (Extension) 
Act of 1915, which is considered later. 

The Act of 1907 permitted Local Authorities to 
adopt a system of compulsory notification of births, 
subject to the consent of the Local Government 

The Notification of Births Act might be adopted 
by any Local Authority. Such local authorities are 
county boroughs and counties, other boroughs, includ- 
ing Metropolitan boroughs, urban and rural district 
councils. (Cf. Chap. XXII.) 

The detailed procedure was as follows : — The adoption 
being decided upon by the council (usually on the re- 
commendation of the health committee), the town 
clerk applied to the Local Government Board for per- 
mission to adopt the Act. The permission was at 
first given only if the Board were satisfied that pro- 
vision was being made to utilise the information ob- 
tained by home visitation, and after such proposals 
had been duly advertised in the local papers. These 
conditions being satisfied, the Local Government Board, 
with the concurrence of the local authority, fixed the 
date on which the Act would come into force. 

Although the Act gave power to the county coimcils, 
except the London County Council, to adopt the Act, the 
Local Government Board did not at first encourage these 
authorities to undertake the work. It is, however, 
precisely in the scattered districts which are found in 
country areas that the work is most difficult to carry 
out. A number of smaller districts were willing to do 
something to improve the condition of the babies born 
in their area, but were unable or unwilling to employ 


some one specially for this purpose. Events have shown 
that the county council is the proper authority to 
take on the work, at all events for the less populated 
areas within its boundaries. A few county councils, 
notably Warwickshire and Worcestershire, who were 
most determined to get the work started, succeeded in 
persuading all the districts within their purview to adopt 
the Act,'and then to arrange with the county council to do 
the work. This policy did not, however, tend to promote 
the adoption of the Act in rural areas, and after a few 
years it was found necessary to secure the adoption of the 
Act by county councils wherever possible. 

When adopted and in force, the Act required the parent, 
or any other person present at the birth, or in attendance 
upon the mother within six hours after the birth of the 
child to notify, within thirty-six hours, the occurrence of 
the birth to the medical ofl&cer of health for the district. 
Failure to notify might involve a penalty not exceeding 

Notification is required of all viable children whether 
alive or dead, that is, of all children born after the 
twenty-eighth week of pregnancy. 

It is important to note that the duty of notification was 
primarily laid upon the parent, because it has often been 
contended that the duty was laid upon the doctor or 
the midwife in attendance, and great objection raised 
to the absence of a professional fee for notification. 

The error has no doubt arisen from the fact that 
doctors and midwives are the only persons authorised 
by law to attend births, and are registered and known. 
Tt is therefore easier to draw the attention of doctors 
and midwives to the requirements of the Act than to 
inform the parents. Moreover, the Act provides that 
notification forms shall be provided by the local 
authority free of charge and prepaid for the post so as 
to avoid any expense to the person notifying. 

As it would be impossible to send one to the parents, 


who are not known beforehand, it was evidently necessary 
to send the forms to the doctors and midwives, who 
could then either hand the form to the parent or fill it 
in themselves. The notification form is either a folder 
or a postcard addressed to the medical officer of health. 
A sample folder is shown below. 



No. 3662. 

/ hereby give you notice of the birth of a child * at 


State whether born alive or dead 

Sex Date of Birth 

Name of Parent 

Parentis occupation 

Name and address of the person giving the notice 

Doctor's Name 

Midxvife's Name 

Dale of -Notice 

* This notice applies to any child bom " after the expiration 
of the twenty-eighth week of pregnancy, whether alive or dead." 

Notification of Births Act, 1907. 

suboiary of the provisions of sectio^ one. 

The " duty " of notifying a birth to the medical officer of 
health devolves, in the first instance, upon the father of the 
child, if he be living in the house at the time of the occurrence 
of the birth ; and if not, then upon " any person in attendance 
upon the mother at the time of, or within six hours after the 
birth." The notice must be " given by posting a prepaid 
letter or prepaid postcard . . . within thirty-six hours after 
the birth " ; or by delivering a *' written notice of the birth 
at the office or residence of the medical officer within the same 
time." The notification is in addition to, and not in substitu- 
tion for, the requirements of any Act " relating to the registra- 
tion of births," and it applies to any child born " after the 
expiration of the twenty-eighth week of pregnancy, whether 
alive or dead." Liability to penalty not exceeding twenty 
shillings is incurred by any poi-son who fails to give notice of a 
birth in accordance with th<f Act. 


Slight variations occur in the forms used in the diff- 
erent areas, but the differences are not important. The 
Act only allows a halfpenny to be spent on postage for 
each form. Some local authorities used halfpenny 
postcards, but the publicity involvedproved an objection, 
and some form of folder is commonly used. 

The majority of births are now attended by mid wives 
(cf. p. 147), and it has been found that the notification 
forms are in most cases filled in by the midwife in attend- 
ance ; the medical practitioners fill in a proportion of 
the notification of births attended by them, and the 
small remainder are dealt with by the parents or some 
other person present at the birth. 

A comparison of the births notified with those regis- 
tered shows, in most districts, that all births are not 
notified. The percentage of notification varies from 
80 per cent, to 90 per cent, in most areas, while a 
few claim that complete notification is secured. The 
cases not notified are usually those among better-to-do 
persons occurring in doctors' practices. 

The notifications are carefully preserved in the Public 
Health Department, the information given entered in a 
register and the appropriate visitor supplied with the 
details necessary for her work (cf. p. 19). 

The Act was adopted at once by a large number of 
great towns, and certain of the Metropolitan boroughs. 
In 1909 it became compulsory for the Metropolitan area 
by order of the Local Government Board.' Rapid 
extension of its adoption took place in 1912-14, and in 
1915, 80 per cent, of the whole population of England and 
Wales had come under the Act. The Notification of 
Births Extension Act of 1915 brought in the remaining 
20 per cent, compulsorily. In effect the remaining 
20 per cent, of the population were almost entirely in 
rural areas, there being then only an insignificant number 
of towns which had not adopted the Act. The rural 
districts had special difficulties in carrying out any work 


under the Act, and had therefore not applied for its 

The Act of 1907 carried with it no powers to spend 
money out of the rates on work undertaken under the 
Act, and no Exchequer grants were available (for 
further information, see Chap. XXV). The only way in 
which it was permissible for local authorities to pay the 
salaries of the visitors employed by them, was to regard 
them as sanitary inspectors. A Bill (The Health 
Visitors' Bill), introduced by Mr. Burns to remedy 
the difficulty, failed to secure passage through the House 
of Commons. Power to employ health visitors was 
given to the Metropolitan boroughs by the London 
County Council General Powers Act of 1908. 

Those local authorities whose accounts are subject to 
government audit ^ found themselves in a somewhat 
ambiguous position until the Act of 1915 gave definite 
power to levy rates for infant welfare work. In 1914 
Exchequer grants became available, but there was 
no clear parliamentary authority for the spending of 
rates on infant welfare work. Many of the larger 
local authorities had undertaken considerable annual 
expenditure for this purpose, and much work was being 
carried on before the Act of 1915 was passed. 

Apart from the activities of local authorities, much 
work was being done by voluntary agencies. This was 
especially! the case in certain towns where the local 
authority was either unwilling or afraid to incur ex- 
penditure. In some of these, the names and addresses of 
the infants whose births were notified were passed on for 

* The aooounts of county oonnoils, of certain of the municipal 
boroughs, the Metropolitan bon)Ugh8, the urban dlBtricts and 
rural districts are audited by govommcnt auditors attached to 
the Local (}o\ernment Board (now the Ministry of Health), whose 
duty it is to disallow all expenditure for which there is no statutory 
authority. Those members of the authority who give instructions 
for any unauthorised expenditure are liable to bo surcharged and 
to be required to repay the money. 


visiting to the voluntary agency. In others, the local 
authority employed a visitor to pay the first visit, and 
the voluntary agency was supplied with notes of those 
requiring visiting. A great variety of arrangement 
obtained, but during the past few years the work of 
home visitation under the Notification of Births Acts 
has been taken over almost exclusively by the local 
authorities, and in the provinces at the present time there 
are few areas where voluntary agencies undertake this 
work. In London, however, there are several districts 
where voluntary agencies do the visiting after notifi- 

The notification of births forms the nucleus around 
which centres the great mass of infant welfare work. 
It is true that it is frequently too late after the birth to 
repair defects in both mother and child, and that, 
wherever possible, care should be begun at a much 
earlier period. At the present time, however, ante- 
natal care can only be effectively carried out in a com- 
paratively small proportion of cases. Alteration and 
development in many directions are necessary before 
ante-natal work will replace or render unnecessary the 
notification of births. 

In addition to the notification of births, the notifi- 
cation of infectious and infective diseases is also of 
importance to child welfare work. As such notifi- 
cations are carried out on different systems, it will be 
more convenient to deal with them under other headings 
(see Chap. XXI). 


The Work under the Notification of Births Acts 

The initial duty under the Notification of Births Act is 
the home visitation. Under the Act all births should 
be notified, whether occurring among rich or poor. 
If the better-to-do inhabitants are visited as well as 
the poorer ones, the cost will evidently be greater than 
if only the latter were regarded as in need of advice. It 
is contended that the former can afford such assistance 
as they may need and hence should not be visited. 
It often happens, however, that those who might be 
regarded as outside the range of visiting by the health 
visitor, are glad to avail themselves of her assistance, and 
it is difficult and probably undesirable to make any 
distinction in the visiting. In some districts it has 
been decided that all houses where a birth occurs shall be 
visited, of whatever social standing, but in many places 
the visiting is confined to houses below a certain rental. 
Before the war a rental of £30 per annum was fre- 
quently taken as the limitation above which no visits 
were paid. In every case, however, this was left to the 
discretion of the locality guided by the advice of the 
medical officer of health. In each town the streets are 
well known to the Public Health Department, and little 
difficulty has usually been experienced in determining 
the areas and houses to be visited. Very often requests 
are made for visiting by those who had not been regarded 
as ))cing in need of assistance. 
About 80 per cent, of all births fall within the range of 



infant visiting. This figure may appear to be unduly 
high, but in fact it is remarkably constant, since where 
there is a large better-class population the birth-rate 
among them is usually low, the births occurring mainly 
among the poorer classes. In a few districts the per- 
centage of births requiring visits is considerably above 
80 per cent., and may reach 90 per cent, or more. 

When the visiting is carried out by a voluntary 
society it is usual for the society to have a district 
allotted to them and the medical officer of health sends 
on to them only the births which he considers suitable for 
visiting. In some cases the visitor of the authority pays 
the first visit, and then sends on the name and address 
to the voluntary agency. 

Date of the First Visit. — Either a doctor or a midwife 
attends every birth, and each is responsible for giving 
advice to the mother during the period usually recog- 
nised as the length of attendance. 

Doctors usually remain in charge for fourteen days after 
the birth, and midwives for ten days. The doctor does 
not, however, usually attend every day, and can hardly 
reasonably be expected under the present conditions to 
give the time needed for detailed advice to the mother 
as to the hygiene of the child, especially in many of the 
poorer cases. The midwife is expected to attend 
frequently, and in the case of a great many midwives 
the necessary advice and care are no doubt given. There 
are, however, still a number of midwives in practice who 
are not capable of giving the advice required, since they 
are themselves untrained, and when they are in attend- 
ance at the birth it is usually felt that the visitor 
should visit at once on receipt of the notification. 

The medical officer of health decides the date at 
which the first visit shall be paid, having regard to the 
qualifications of the person who is in attendance. It is 
unusual to visit doctors' cases within fourteen days unless 
a request for this is made on the notification form, or it 


is known that any special practitioner is glad of the 
assistance of the \asitor. There is no rule as to the date 
of the visit in midwives' cases, and the practice varies 
according to the views of the medical ofl&cer of health 
and the known capacity of the individual midwife. 
Probably, however, in the aggregate the visits are 
most frequently paid after the period of the midwife's 
attendance has ceased. 

The health visitor has no legal right of entry to a 
house. She can enter only by the permission of the 
occupier. The sanitary inspector has the legal right 
of entry in the performance of his or her duties, and 
efforts have been made at intervals to secure a similar 
right for the infant visitor. So far, however, this has 
not been received with enthusiasm either by the 
Local Government Board or by most of the local 
authorities. It is felt that if the visitor needs legal 
powers to enable her to get into the home, her advice 
will probably not be followed, and, since she needs to be 
on friendly terms with the mother, it is preferable for 
her to obtain entrance by tact alone. In practice a 
suitable visitor very rarely fails to obtain admission. 

Leaflets. — A great many local authorities distribute 
leaflets on bow to look after the baby, and these are 
sometimes sent by post at once on receipt of the notifica- 
tion, and sometimes distributed by the visitor at her 
visit. The value of these leaflets is much debated. 
Some people no doubt read them, but many do not, or if 
they do, make no attempt to follow the instruction. 
Then again, the instruction given differs widely in 
different districts, and unfortunately the advice given 
in the leaflets is by no means always the best, being 
often of the old-fashioned type. Thus, in London, in 
adjacent streets, the mothers may receive different or 
even opposite advice owing to the boundary line between 
two districts falling in that area. The leaflets vary 
from small slips of paper with a few salient maxims, to 


large cards filled with, advice which can be hung on 
the wall, and are sometimes booklets of considerable 
size. Their value probably varies with the character 
of the population and with the degree to which the 
visitor feels able to draw the mother's attention to them. 

Record Cards. — One of these is provided in each case.^ 
In the larger public health offices, the name, sex, date 
of birth, address, and any further information obtained 
from the notification form is usually filled in by the 
clerical staff. The record cards show almost as great 
variety as the leaflets. The object of the card is to 
record such information about the child as may be 
considered of value in connection with its health. This 
will include the place in the family, the number of other 
children, the general condition of health of the parents 
and children, the conditions of the home, whether airy 
or confined, sanitary or insanitary, the methods of feeding 
the child, and other relevant matter. It is evident that 
all the information cannot be gained at one visit, but 
must be obtained gradually. As the visitor gets better 
acquainted with the mother, she usuallyihas no difficulty 
in gaining any information she needs. In fact, she 
usually receives far more than is required for her record 
card. '^ 

It is not advisable to fill in the cards while paying the 
visit. The information should be memorised and written 
down on the record card outside the house, preferably 
round the street comer. Some local authorities 
provide neat little^ cases or satchels for each visitor and 
a fountain pen, so^that the card can be filled up while 
on a round, thus saving the time which would be re- 
quired later at the office if notes are to be copied on the 
cards. Space is provided on the cards for notes as to 
the progress of the child at subsequent visits, and it is 
very desirable that the record should be continued up 
to the age at which the child attends school. The card, 
* Samples are shown in Appendix I. 


or an abstract of it, should then be available for the 
school medical' ojficer, and^will be of the greatest assist- 
ance in deaUng with health questions while the child 
is at school. Where the child attends a child welfare 
centre, arrangements are necessary to render the in- 
formation obtained at the visits available for the 
medical ofl&cer at the centre, and also that informa- 
tion obtained at the centre should be available for the 
visitor (cf. pp. 46 and 47). 

(For a sample record card see Appendix I.) 

The Duties of the Visitor. — Health visitors appointed 
by the local authority form part of the staff of the 
Public Health Department and are imder the medical 
officer of health. In most large towns there will be 
assistant medical officers of health, and in this case one 
of the assistants will probably be specially appointed 
to supervise the child welfare work. Sometimes an 
assistant medical officer of health is appointed ex- 
pressly for this work, and may also be the medical officer 
of the child welfare centre or centres. 

A health visitor should always remember that it is 
her duty to carry out the instructions of her chief loyally 
whether his directions correspond precisely with her 
own \aews or not. It is usual for a definite time to be 
set apart when the visitors can see the medical officer. 
These interviews afford a valuable opportunity to the 
medical officer of hearing the information a visitor may 
have to impart about her district, and of giving the 
advice of which the health visitor may be in need in 
regard to any special case. 

The date at which the visit is paid will affect the 
duties of the visitor. If paid early after notification, 
while the mother is still in bed, the most important duty 
will be to make inquiries about the feeding and to per- 
suade the mother to breast-feed the child, but it will 
usually be undesirable to remain more than a few 
minutea. It is often po88il)Ie to note the sanitary con- 


ditions of the premises at the first visit, since this does 
not disturb the mother. One examination is not suffi- 
cient, but the visitor, throughout the period of her 
visiting, be it long or short, should see that insanitary 
conditions are noted and dealt with. At subsequent 
visits she will become more closely acquainted with the 
affairs of the family. While always ready to listen, 
the visitor should not appear inquisitive, and any infor- 
mation obtained is strictly confidential and must on no 
account be communicated to neighbours. Some people 
consider it advisable that the visitor should inquire into 
the wages earned by the father or by the other members 
of the household, if any. This inquiry is, however, often 
very naturally resented, and sometimes the woman herself 
does not know what her husband is receiving. The 
object of the inquiry is to ascertain what the mother 
is able to afford for the child, and whether the money is 
sufficient but is being misspent. A tactful visitor is 
nearly always able to judge whether the mother is able 
to afford all that is necessary for the child without 
asking about the family income. 

It is well to remember that, in a sense, the visits are 
in the nature of an intrusion and that the visitor is 
admitted by courtesy and not by right. She should 
therefore refrain, unless in very special cases, from 
behaviour which she would not adopt on any friendly 
visit to her own acquaintances. 

The Sanitary Condition of the Premises. — The 
visitor must note the general condition of the house or 
dwelling : the condition and cleanliness of the walls and 
floors : the arrangements for ventilation and presence of 
any overcrowding : the water-supply : the nature of the 
sanitary arrangements : the condition of the backyard 
or garden, if any : the arrangements for the disposal of 
refuse : the facilities for getting air for the child : for 
the storage of food, especially for the infant's milk, if 
artificially fed. There will also be other points which 


will present themselves to the experienced visitor. 
When defects are present, the visitor must endeavour 
to get them remedied. Ordinarily, she will report de- 
fects in sanitation to the medical officer of health or to 
the sanitary inspector, but certain of the above matters 
can often be remedied by the people themselves if they 
are persuaded of the desirability for doing so. 

She should be sufficiently acquainted with the law 
and with local practice to be aware which of these 
matters require reporting and which do not. 

Where the visitor is qualified as a sanitary inspector 
she can, if desired, deal with the defects herself. This 
may, however, lead to difficulty with the landlord, and, 
in general, it is the practice for the visitor to hand 
over any procedure which may be necessary to the 
recognised officer. In view of the present housing 
conditions, the people are frequently afraid of any repre- 
sentation being made to their landlord, lest they should 
be turned out in favour of other more complaisant 
tenants, and often beg the visitor not to let the landlord 
be annoyed by requests for improvements. 

In some few places the practice of allowing the visitors 
to deal with sanitary defects discovered by them obtains, 
and has been found to be entirely unobjectionable. At 
the same time, the majority of medical officers of 
health seem to prefer that the sanitary defects should be 
referred to the sanitary inspectors, and this view is 
taken by the Ministry of Health in a recent circular 
on child welfare. 

The Hygiene of the Infant. — The visitor should 
be prepared to give advice as to the feeding of infants 
both before and after weaning, and of young children. 
She should be fully acquainted with the technique of 
breast-feeding, and should do her utmost to secure 
this for the mfant. Failing the natural method, she 
should be able to advise simple methods of artificial 
feeding, and should instruct the mother in the necessary 


details. Further, the clothing, bathing and general 
cleanUness of the child, its sleeping arrangements by- 
day and by night, the amount of fresh air it obtains, the 
ventilation of the room or rooms it may occupy, and 
the state of the bowels and of the skin all fall within the 
province of the visitor. Where there is an infant 
welfare centre in the neighbourhood, and this is 
usually the case at the present day, the visitor should 
invite the mother to attend, and should tell her the day 
and hour when the centre is open. 

In a few places the visitor is provided with a hammock 
which can be suspended from the hook of a spring balance. 
The baby (usually with its clothes, since the mother 
does not want the trouble of undressing it) is placed in 
the hammock, and the weight entered on the record card. 
Apart from the error of the clothes, which will inevitably 
differ at each visit, the child rarely remains still in the 
hammock, and the level of the pointer oscillates on the 
scale, rendering it impossible to read with any degree of 
accuracy. Such a method as weighing is of Uttle or 
no value, and weighing is best omitted from the duties 
of a visitor on her district. 

There is a superstition which is very prevalent in 
many parts, to the effect that if a baby is weighed 
it will die. The origin of this beUef has, so far, it is 
beUeved, not been explained, but it seems possible that 
it may be a survival in an altered form of the dread 
of punishment similar to that visited on Israel and 
Judah after the numbering of the people by David. 

A health visitor must reaUse the importance of de- 
tecting early indications of oncoming trouble. If, for 
example, the child is not thriviag, or its progress from 
being quite satisfactory becomes less so, she should not 
wait until the trouble, whatever it may be, has got well 
established, but should endeavour to ascertain what it 
may be that is the cause of the lack of progress. It may 
be that on careful inquiry she may find that the mother 


has been giving different food, or has failed to give the 
child fresh air, and so on. If, however, there is no 
apparent cause she should endeavour, if possible, to per- 
suade the mother to bring the child up to the centre 
to see the doctor, or if this is already being done, she 
should advise that the mother should not fail to attend 
on the next possible occasion. Where the child is 
clearly ill, it will probably be advisable to recommend 
the mother to seek the advice of her own doctor, but 
some centres consider that the child should be sent on 
to the family doctor from the centre rather than by the 
health visitor. 

A visitor must in no case undertake treatment as 
distinct from hygienic advice. 

Social and Industrial Conditions, etc. — A visitor 
will need to know about the conditions of work, etc., 
which concern the famihes she is visiting. In a rural 
area the life is bound up ^vith the various seasons, with 
the weather, the kind of crops most prevalent in the 
particular districts, etc., and the visitor will do 
better and more intelUgent work if she makes herself 
acquainted with these and similar matters. 

Most districts have conditions which are common to 
other districts of similar type, and also other special 
conditions peculiar to the locality. 

In the towns or industrial areas she will need to know 
about the conditions under which the men and women, 
the boys and girls, work : of the chief types of amusement 
available, the social organisations to which they may 
or should belong. For instance, in a mining area, the 
work of the housewife is rendered very arduous by the 
shifts worked by her husband and perhaps by a lodger or 
relation living with them. In other districts there will 
be other difficulties connected especially with the pre- 
vailing employment of the inhabitants. 

She should know something at least about the question 
of insurance under the National Insurance Act, of trade 


unions and their rules, of clubs of various kinds, in fact, 
all that affects the lives of those she visits should be of 
interest to her. 

Certain of the above matters are technical and not 
easy to understand without explanation. Such ex- 
planation should now be given in the training for 
health visiting which requires instruction in social and 
economic conditions. 

The visitor is dealing with the complexities of human 
life, and the more she is able to enter into the varied 
conditions of the Ufe of those among whom she visits, 
the greater will be the value of her speciaUsed work. 

Other Matters. — The formidable list of subjects 
already enumerated does not, however, complete the 
duties of an infant visitor. As she becomes friendly 
with the mother she will find that her advice is asked 
on all kinds of matters, some of which may have only 
an indirect bearing on her work. She will often need 
to bring to bear all her past experience in order to answer 
the questions put. In some homes circumstances are 
found which present very real difficulty to the visitor. 
Here and there a mother is found who seems to have 
no affection for her children, who are neglected and 
wretched. The efforts and persuasion of the visitor 
may, with patience, succeed in effecting astonishing 
transformations. Occasionally, however, it may be 
necessary for more drastic treatment to be adopted. 
In such a case, the medical officer of health may con- 
sider it advisable to refer the case to the officer of 
the National Society for the Prevention of Cruelty 
to Children, a procedure which often secures good 

There are few visitors of experience who have not in 
their memory cases which have required continual and 
persistent visiting, advice and cajoling, in fact, all forms 
of inducement for a prolonged period before that 
realisation of her duties in the mother has been pro- 


duced whicli makes her secure healthy conditions for 
the child. 

The visitor must remember that she is not a mis- 
sioner but a health agent. Her duty is not to condemn 
or to preach. She will inevitably find immoral con- 
ditions among some of those she visits, but except in so 
far as those conditions may cause direct injury to 
health they are not her concern. Voluntary workers 
may find it difficult to refrain from advice and admoni- 
tion in these matters, but the health visitor must dis- 
creetly avoid any interference in the lives of those she 
visits. If this is realised she will often be given oppor- 
tunity of assistance which she would otherwise miss. 

Whoever would do useful work among the poorer 
classes must try and understand the views upon various 
matters held by those among whom the work is to be 
done. It is too frequently forgotten that the life of 
those who live in humble circumstances is altogether 
more primitive than is usually the case in the classes 
from which the workers are most often taken. Differ- 
ent classes of society are prone to condone different 
faults. It is always easier to see the faults of those 
among whom we have not been brought up ; but, ex- 
cept in so far as health may be concerned, it is no more 
the duty of the health visitor to expatiate to those she 
visits upon their faults, than if she were visiting her 
own friends. A friend who is inclined to chide is not 
likely to receive confidence or to be allowed to give aid 
or advice. 


The Relation of the Child Welfare Visitor to 
Charitable and Social Organisations 

At the present time the whole attitude of many thought- 
ful persons is undergoing, or has already undergone, 
much change from that of some twenty years ago or 
less. The old idea of giving money or other material 
assistance to cases of obvious poverty without further 
inquiry has now nearly passed away. It is recognised 
that apparent poverty may be due to other causes than 
lack of income, and that investigation is needed, be- 
cause indiscriminate and unsuitable gifts are more^likely 
to do harm than good. The official^recognised organisa- 
tion for public relief is the Poor Law, but, from various 
reasons, mostly well known, recourse is only had to the 
Poor Law by those who are unable to obtain help in 
any other way, or who have been proved impossible 
to aid from other sources. Until recently, at any rate, 
the Public Health Department has not had power to 
give material aid in any form, and material aid has 
usually been regarded as undesirable. All forms of 
work which tend directly to prevent disease are now 
coming to be regarded as a duty which has to be carried 
out by public bodies, and as conferring benefits, which 
are the right of the public and in no sense charity.^ 
Every visitor among the poor will not fail to meet 

^ It is impossible to say how far the present position of the Public 
Health Department may be modified if, and when, the abolition 
of the Poor Law comes to pass. 



cases of poverty where common humanity appears to 
demand instant material aid. In one or two towns the 
infant visitors have been allowed to collect money, and 
to distribute it among cases which appear to be necessi- 
tous. Ordinarily, however, it is agreed that material 
relief should in no case be given by the infant visitor. 
In the first place, the inhabitants of her district should 
not regard her as a source of aid in apparent poverty, 
which will be the case if she distributes relief, and, 
secondly, such reUef is palKative only, and may be 
directly detrimental unless given with due knowledge 
of the family circumstances. The visitor is hardly 
ever a trained relief worker, and does not therefore know 
the best means of affording lasting aid. Organisations 
of various forms, to which cases can be referred, exist 
in nearly all districts. It is sometimes said that certain 
well-known organisations are too slow or too particular 
in their methods, but even if this statement be deemed 
justifiable, there should be no difficulty in arranging 
for speedy relief apart from the infant visitor. The 
visitor should be well acquainted with the various 
possible sources of aid in her district, and she should 
refer the needy cases to whichever of these sources appears 
to be the most appropriate to each case as it arises. 

The provision of free or cheap dinners or food for 
mothers and of milk for infants is a very debatable 
point. So long as such aid is provided only on medical 
orders, and this is clearly understood by the recipient, 
little or no objection need be raised from the point of 
view of reUef. It will nearly always be a temporary 
measure to tide over a special period in the life of either 
child or mother. The distribution without much in- 
vestigation of free orders for milk for infants needs to 
be closely watched lest it should tend to encourage 
artificial feeding.^ 

* It l» greatly to be ho])ed that the present high prices of milk 
may produco greater attention to breast-leeding on the part of 


Again, there will be cases where it may seem that letters 
for some convalescent home or rest home for mothers 
with some form of aid for a child are required. The 
infant vistor should not herself take any steps to pro- 
vide such aid, but she should possess a sufl&cient know- 
ledge of the aim and objects of the manifold charitable 
and social organisations, both generally and in her own 
district, to be able to direct the mother or herself to 
make application to the appropriate agency, either 
directly or through the chief health visitor, according to 
circumstances. It has often happened that a well-mean- 
ing ignorant visitor has expended much time and trouble 
in securing what appeared to her to be the right form 
of assistance, when the case was well known to existing 
appropriate agencies who either had already made 
similar arrangements for aid, or who knew that the 
proposed form of aid was entirely unsuitable for the 
particular case. Overlapping of effort should be avoided 
and no one set of workers should trench upon the field 
of others. 

all concerned and that it will not lead to an increased supply of 
free or nearly free milk for artificial feeding. 


Points in the Arrangements and the Conditions 
OF Work of an Infant Visitor. 

It is assumed in tliis chapter that the visitor under- 
takes no other work than that connected with infants. 
In the earher years of the movement it was common in 
the towns to allot to the health visitor other duties 
beside those arising under the notification of births. 
The ^\ork in connection with and arising out of the 
medical inspection of school children, and the work 
among tuberculous persons were the most important of 
the other activities. In the towns, however, the visitors 
are now increasingly being given only the work among 
mothers and children under school age. In the 
counties, on the other hand, owing to the relatively 
scattered position of the population the tendency is 
to place a variety of duties upon the health visitor for 
each district. It is easier, however, to deal first of 
all exclusively with the work among infants and after- 
wards to consider the modifications (cf. Chaps. X 
and XI). 

The arrangements made for the work of the visitor 
will depend a good deal on the nature of the district, 
whether the population is congested or scattered. In 
a large town it is usual to employ a number of visitors, 
of whom one is the chief visitor. The town is then 
divided into districts and a visitor allotted to each. 
The size of the district will depend upon the average 
number of births which occur in the year. As a rule, the 


poorer the district, the smaller it will need to be. In 
addition to the number of births, the facilities of transit 
will be considered and the areas arranged so that there 
is the least waste of time in getting to and about the 

The chief visitor may have a small district of her own 
if she has time, but in a really large town it will probably 
only be possible for her to supervise and arrange the 
work of the other visitors and to visit especially difficult 
cases when her assistance is requested. 

The notification of the births will be handed to the 
visitor of the district who will be responsible for visiting. 
Although it may be the nominal practice to visit doctors' 
cases on the fifteenth day and midwives' cases on the 
eleventh, it is not always possible for this to be done 
without undue loss of time, unless the area worked by 
one person is very small and congested. A visitor learns 
to arrange her work beforehand, so that there are a 
number of visits to be paid in adjacent streets, and it may 
cause the loss of eight or ten visits if she is obUged to 
pay a single visit in a district where no other visits happen 
to be due. The less congested the area, the more difficult 
it is to adhere at all strictly to any set day for the first 

Opinions differ widely as to the frequency with which 
visits should be paid. It is usually agreed that much 
must be left to the discretion of the visitor. There 
will be a number of cases where an occasional visit is 
all that is necessary. The mother may be well-to-do 
and the child well cared for. In such a case the visitor 
may pay a quarterly visit or she may ask the mother to 
send a card if there is anything she would care to see her 
about. It is rather surprising to find how much advan- 
tage is taken in some districts of this offer : it might have 
been thought that the trouble of writing would have 
acted as a deterrent. 

Again, there will be other cases where much assistance 


is needed and where weekly or more frequent visits will 
be necessary if any improvement is to be effected. Then 
there are the cases where fairly regular visits are desirable. 
Some people consider that monthly visits are too fre- 
quent for the average case, while others regard a fort- 
night as the longest interval which should be allowed 
to elapse at any rate in the early months after birth. 
There can be no rule laid down — much depends upon 
the character of the people and of the visitor and each 
case must be dealt with on its own merits. Again, as 
the child grows older fewer visits will be necessary. If 
the visiting is continued up to school age, as should be 
the case, it may roughly be computed that the number 
of visits in the four years from one to five will be about 
equal to those necessary in the first year alone. 

It has been found that on the average a visitor en- 
gaged only with children under one year, can undertake 
the visiting for approximately twice as many births in 
the year as one who continues visiting up to school age. 
Here, again, however, there will be much variation. The 
most recent circular upon the subject issued by the 
Local Government Board allows 400 births to one 
visitor. Certainly not more than 200-250 children up 
to school age can be dealt with by one visitor. At first, 
under the Notification of Births Acts, it was a not in- 
frequent practice for one visit only to be paid, subse- 
quent visits not being regarded as falhng into the same 
category. Later, as the work developed, it was reaUsed 
that one visit without re-visits was waste of effort and 
visits were usually continued up to the end of the first 

In 1915 the Local Government Board regarded 500 
births as the number which could be allotted to one 
visitor. Great consternation and doubt were expressed 
by many councils at the immense number of visitors 
who would be necessary under such a proposal It is 
now generally known that much effort is wasted if the 


visiting ceases at the end of the first year and in some 
places already the aim is to allot not more than 250 
births per annum to each visitor and to require visiting 
up to school age. 

The number of visits which can be paid in the day 
or the year will again depend on the nature of the dis- 
trict, on whether the visits are early visits or late ones — 
as a rule early visits take longer than those paid when 
the child is older. Ordinarily a visitor will not be able 
to accomplish more than fifteen to seventeen visits in 
the day under favourable circumstances. When the 
homes visited are not grouped, or when there are 
several first or early visits, it will not be possible to 
pay so many. Again, much will depend upon the 
distance from her office, which is usually the Public 
Health Department, and which may be some distance 
from the district to which the visitor is allotted — also 
whether she bicycles or walks or takes a tram, etc.^ 

Then, again, the amount of office work required will 
affect the number of visits paid. If the visitor has to 
spend an hour or more copying notes and records either 
before going out or after returning from her work, 
there will be less time for visiting. The hours available 
for visiting are ordinarily rather limited. The tidy 
mother does not like to be found at her work, and she 
likes a little time for clearing up after the children (if 
any of school age) have been got off to school There- 
fore usually it is best not to visit much before 10 a.m. 
unless the visitor knows the mother, and is sure of her 
welcome. Then, visits should not be paid during the 
dinner hour, especially if the husband comes home to 
dinner ; moreover, preparations for dinner are necessary, 

1 It is usual where the tramways are owned by the Corporation 
to give free or reduced tickets to the visitors when using the trams 
for their work. Their travelling expenses incurred in connection 
with their work are paid. It is usual also to provide the health 
visitor with an annual sum for the upkeep of her bicycle, and in 
Bome cases the bicycle itself is provided. 



and the housewife who has just left time to get dinner 
ready may not be pleased at a ten minutes' interruption 
at a critical moment in her culinary arrangements. In 
the afternoon, of course, they are often out, and the chil- 
dren return from schoolat 4 p.m., or earher in some places, 
in the winter. Visits paid at inconvenient times do not 
conduce to a welcome or to obtaining good results. A 
certain number of visits will often be abortive, the 
mother being out, but after a little while the habits of 
the district or of particular women get known, and the 
visitor develops an instinct for finding the mothers at 

In a scattered area, or in the country, it is impossible 
to arrange for more than occasional visits owing to the 
distance apart of the homes. Much will naturally 
depend upon the size of the district the visitor has to 
work, but generally very different standards of frequency 
are adopted in towns and in country districts. 

Where there is a child welfare centre in the visitor's 
district, arrangements are usually made for her to attend 
the centre. It is sometimes urged that by doing so 
the visitor cannot pay as many visits as are required for 
her cases. Both from the point of view of the visitor 
as well as of the mother, it is essential that she should 
arrange to attend the centre. She will be more success- 
ful, because more interested, in persuading the mother to 
come up if she knows she will be there herself, and the 
mother will feel less strange if the visitor is there to 
welcome her. Again, it acts as a stimulus to the visitor 
and, if she is present at the consultation, as should be the 
case, she is better able to see that the advice given at the 
consultation is carried out. 

The Ministry of Health are now advising local 
authorities to arrange as far as possible tliat each visitor 
shall be attached to a centre, and that the area served 
by the centre shall be coterminous with the visitor's 
district, or where the centre serves the districts of two 


visitors, separate sessions should be allocated to the 
different districts. The centres would thus be small 
centres, and their primary function would be the giving 
of medical advice. There would thus be many small 
centres, each serving a particular locality, and a few 
larger centres where other activities are available, serving 
the districts of a number of visitors. 

Still-Births. — A feature of the visitor's work which 
obtains almost universally among the staffs of local 
sanitary authorities is the visits paid in regard to still- 
births. The problem of still-births is very intricate. It 
was not usual to register children who were born dead, but 
notification of all viable children {i.e., after the twenty- 
eighth week of pregnancy) is required whether the child is 
born dead or alive. Formerly, the still-born child was not 
infrequently taken to the undertaker, who placed it in any 
cofl&n which was about to be taken to the cemetery, and 
the child was buried without further ado. But, with the 
notification of still-births, the practice ceased, and tbe 
medical officers of health required the visitor to pay 
visits to the homes of all still-births, and to make special 
inquiry into the occurrence. Although, doubtless, some 
still-births are unpreventable, it is probable that a fair 
proportion could be prevented, and in certain cases 
no doubt a still -birth is not regarded as a misfortune. 

In one large town no burial of a still-birth may take 
place until the body has been seen by the visitor for the 
district, or by the chief visitor, and a permit for burial 
received from the Public Health Office. Accurate 
figures as to the number of still-births are only avail- 
able for a few towns. The midwives usually notify all 
the cases occurring in their practice, but it is well known 
that this is not the case in doctors' practices. Hence the 
still-births notified do not give a correct figure. The 
only method of obtaining the true figure is from the 
returns of the cemeteries, through the certificates of 
death. The figure of 3 per cent, which has been widely 


published as the average figure for still-births is subject 
to the limitation of available information mentioned 

Ante-natal Work. — Experience has shown that visits 
paid at the times above described are very often too 
late. The child has been taken ofi the breast, and efforts 
to restore natural feeding are unsuccessful, or no effort 
at all has been made by the mother to undertake this 
duty, and artificial feeding is firmly estabUshed when the 
visitor arrives. Again, unsatisfactory clothing has been 
provided, and the money having been spent, no more is 
available — ailments in the mother or conditions in the 
home could have been attended to had the visits been 
commenced before the child was born. These and other 
considerations have led to the demand for ante-natal 
visits on the part of the visitors. 

There can be no doubt of the need for ante-natal care, 
but it is questionable whether it can be regarded as 
falling within the purview of the work of the visitor. 
When a doctor has been engaged, ante-natal visits should 
not be paid without his consent and approval, although 
the nature of the ante-natal care given by the visitor 
or by a midwife should not include anything in the nature 
of treatment. Under her Rules (cf. pp. 129 et seq.) the 
midwife is responsible for her patient as soon as she has 
been engaged to attend the confinement. In the case of 
trained midwives, there can be little doubt that ante- 
natal visits should be carried out by them, but where the 
midwife is herself untrained the position is very different. 

There is the difficulty of knowing wliere the cases are 
that require ante-natal visits, since there is no definite 
means of ascertaining their whereabouts. A visitor 
who knows her district will probably not have much 
trouble in knowing of the majority of cases, but she 
must be careful not to interfere with the midwife or 
doctor engaged by the mother. Apart from these con- 
siderations it is evident that she must have had experi- 



ence in maternity work, and know what advice to give. 
Thisfat once raises the whole question of the training 
of visitors as midwives. It is generally agreed that 
without a midwifery training, they cannot undertake 
ante-natal work, but also the mere training in mid- 
wifery is not enough, and actual practical experience in 
midwifery on the part of the ante-natal visitor must be 
regarded as essential. The visitor should have been a 
practising midwife if she is to undertake this work. 
This subject is considered further in later chapters. 

The Ministry of Health have recently stated that 
ordinarily the midwife should do the ante-natal work 
for her own cases, although at the present time, where all 
midwives are not trained, this may not be possible. 


The Child Welfare Centre 

Reference has already been made to the child 
welfare centre as exemplified by the infant consulta- 
tion and the school for mothers. At the outset these 
branches of work were very simply arranged, and did 
not overlap one another. The primary function of the 
infant consultation was the medical advice to the mother 
on the means she should employ to preserve the health 
of her child. It was not usual for the attendance to 
be continued after the child had reached one year of 

The school for mothers was intended to be educational, 
the object being to instruct mothers in these matters 
which relate to the welfare of infants generally, and not 
to the particular child of the individual mother. 

It was soon found that neither of these activities was 
self -sufficient. At the infant consultation it was 
realised, for example, that the clothing of the children 
was often quite unsatisfactory, and that the mother 
had no idea how to make proper garments. Many 
of them did not sew at all, and had never cut out a 
garment in their lives. They did not know how to 
mend or alter, how to prepare the food for the growing 
child after weaning, and were frequently ignorant of the 
rudiments of housecraft. 

At the schools for mothers, on the other hand, it was 
found that the mothers were not able to adapt the in- 
formation given on general lines to their own children, 



but were continually asking for advice on special points. 
It was gradually recognised by the schools for mothers 
that they needed an infant consultation, and the infant 
consultations on their part realised that they needed 
some arrangements for the instruction of the mothers 
in the care of infants and of the home generally. 

The functions of the two varieties of centres thus 
tended to approximate, but it was only rarely that any 
change of title was made, and in many instances schools 
for mothers were started whose work was essentially 
that of an infant consultation, but the title " school " 
happened to appeal to those who were responsible for 
commencing the work. 

At an early stage in the movement it was found that 
if the work was to be as useful as possible, it would be 
necessary for the homes of those attending the centres 
to be visited. The establishment of centres and the in- 
itiation of the work under the Notification of Births 
Act commenced about the same time.^ The home 
visitation was at first only undertaken by the large 
towns which adopted the Act as soon as it became 
operative. Even then the visits paid were by no means 
frequent, and often amounted to one visit only. In 
many districts there were at first no arrangements at 
all, t\e Act not having been adopted by the authority 
of the district. 

In some areas there was visiting and no centre, and in 
others there was a centre and no notification of births. 
In the latter cases the visiting had to be done from the 
centre, if it was done at all. In the early years the 
centres were, with very few exceptions, commenced 
and worked by voluntary workers. Usually a number 
of ladies banded themselves together to form a com- 
mittee, which was responsible for all matters connected 

1 The first infant consultation in this country was started by Dr. 
Eric Pritchard at Marylebone in 1906, and the first school for 
mothers by a number of ladies in St. Pancras about the same time. 


with the centre. The cost was not great in those early 

The accommodation usually consisted of not more 
than two rooms of small size, for which a rent of perhaps 
2s. 6d. a week was charged for the one afternoon it was 
opened. All the workers were voluntary, and the 
doctor was asked to give his or her services. As time 
went on and the work increased, it became impossible 
for the visiting to be done by the ladies themselves. 
In some districts it was arranged that the visitor under 
the Notification of Births Act should attend the centre 
and undertake the visiting of the homes of those attend- 
ing as a part of her ordinary work. In other places 
it happened that there was no official visitor, or that 
the ladies preferred to keep the visiting under the 
control of the centre. In this case it was common to 
employ a trained visitor who worked with the centre 
only. She visited those mothers and only those who 
attended the centre, for the primary reason that 
the whereabouts of the others were not known. It 
often happened that the centre could undertake more 
work than it was actually called upon to perform be- 
cause the centre was not known outside a very limited 
area. Quite commonly the medical officer of health 
was asked to supply information as to the address of 
more mothers if the Notification of Births Act had been 
adopted for the district. 

The medical officer of health was often wilUng to 
send on lists of the births in a given area, which area 
was then regarded as allotted to the centre, on the under- 
standing that the centre then assumed responsibihty 
for all the births so notified to them, and that they 
furnished such information about the children as might 
be called for. 

Only in rare cases, however, were the first visits paid 
from the centre. Usually these were paid by the 
Council's visitor in order that the condition of the home, 


etc., might be ascertained and reported to the PubUc 
Health Department. Speaking generally the dual 
system of visiting does not work out very satisfactorily. 
The centres often failed to keep in touch with those 
infants whose mothers did not bring them to the centre, 
so that they received no visits at all. They have been 
handed over to the centre, but the centre, finding that 
they do not attend for medical advice, gradually ceases 
visiting. Those who do not attend a centre are fre- 
quently more in need of visiting and advice than 
those who do, and in this way many cases in real need 
of advice may be neglected. It is seldom that a 
centre can afford to provide a staff of sujSicient size 
to visit cases other than those who form the clientele. 
The mass of homes whence the mother does not attend 
at a centre must be visited by the official workers 
employed by the Council under the Notification of 
Births Act. 

Another arrangement sometimes made was that the 
centre should send weekly or fortnightly lists of the 
infants who were being visited by them, and it was 
then understood that the visitor from the Pubhc Health 
Department would not visit in those homes. Any line 
of demarcation is, however, always likely to leave gaps, 
and as a result a certain number of the children are 
not visited regularly. 

The only satisfactory method of visiting is for the 
ofi&cial health visitors to be responsible for all the visiting 
and for them to attend the centre and be*thus personally 
in touch with it. 

On other grounds also it is essential that the visitors 
should attend the centre in their own district, whether 
the centre be worked by a voluntary agency or by the 
Council. If the visitor does not know what advice has 
been given by the doctor at the centre, it is probable 
that much of the advice will be wasted. The mother 
often wants assistance in carrying it out and the visitor 


cannot help her adequately unless she knows what advice 
has been given. Then again, it is good for the visitor 
herseK. She gets a variety of work and is kept up-to- 
date and alert by contact with the other activities of 
the centre in addition to the fact that she learns by 
hearing the advice given by the doctor. 

It is difl&cult to emphasise too strongly the need that 
the visitor should attend the centre. The two branches 
of work — home visiting and consultation — are not separ- 
ate parts of the work but are interdependent, and any 
system which does not secure the closest co-operation 
will fail to effect the best work. The visitor will take 
more interest in the work if she follows the infant in all 
its phases of care, while the mother will be drawn closer 
to the visitor if they meet at the centre. Even if the 
visitor has to pay rather fewer visits in the week the 
time devoted to work at the centre is well spent. 

At the present time hardly any visiting is done by 
voluntary agencies outside London. The development 
of the work at the centre itself has been a determining 
factor in the handing over of the visiting to the ofl&cial 
visitor. The fimds of a voluntary society do not ordin- 
arily admit of the employment of more staff than is neces- 
sary to actually carry on the work at the centre. 

The large present-day centre has moved far from the 
simple activity of the infant consultation. It will be 
interesting now to study shortly the reasons for this 
development. The need for the infant consultation 
and the teaching of the mothers has already been con- 
sidered, and the other phases have arisen as the work 
expanded. In some districts one activity came first 
and in others different work was taken up in different 
order, but now many centres in large towns have a 
number of these activities at the same centre. 

It was found that many mothers were unable to 
attend the centre owing to the fact that they had several 
children under school age who could not bo left at home 


alone. If these cliildren were brought to the centre in 
considerable numbers the disturbance caused was great. 
They could not reasonably be expected to sit still during 
the whole session and inevitably they made a good deal 
of noise. So a " toddlers' room " had to be arranged 
where these small children could be taken on arrival and 
cared for during the time the mother was at the centre. 
Ladies are usually wilhng to take charge of these little 
ones, and a list of those undertaking this duty should be 
arranged for each session. 

The need for medical supervision of those children 
under school age is now fully realised and provision is 
made at many centres for their examination and for 
advice as to their hygiene. Such examination need not 
take place frequently, but it is found better to arrange 
the work among older children on a different day from 
that among children of one or two years of age. The 
practice varies considerably according to local circum- 
stances, some centres keeping those under two years in 
one category while others make the dividing line earlier. 
Others again do not make any clear division. 

Then it was found that many of the children were 
suffering from some mild nutritional disturbance which 
would yield to a few days in hospital with regular 
feeding, etc. Hence arose the desire for some accommoda- 
tion whereby these children might be supervised for a 
few days and got into good habits. It is quite im- 
possible at present to send these children into an ordinary 
hospital as the accommodation is hopelessly inadequate 
for even serious cases of illness. Hence certain centres 
have started so-called " observation wards " where they 
can keep the cliildren for a few days. In some cases 
these wards are used also for children who, from one 
cause or another, have no one to look after them for 
the time being. This may be due to the mother's illness 
or some other cause. These beds should not, however, 
be used for cases of serious illness. 


Another branch of work is that among the mothers 
themselves, expecially before the birth of the child. 
Ante-natal work is increasing and its importance is being 
realised. This branch leads into the whole sphere of 
maternity and midwifery work, and some centres now 
employ midwives of their own. 

The provision of dental care has been found to be one 
of the most valuable branches of work at a centre. This 
is needed for all ages, for the mothers and for the children 
who, too soon after cutting their first teeth, show signs 
of dental decay and before they reach the age to attend 
school have already in many cases sustained permanent 
injury to both teeth and jaw. 

A large centre may therefore be a veritable hive of 
activities, but it is advisable that there should also be 
numerous smaller centres where the ordinary infant 
consultation with its advice and instruction for mothers 
is offered without all the expensive varieties of work of a 
large centre. The various phases will be dealt with in 
more detail in the next chapter, only those forms of work 
which are found in nearly all centres being dealt with in 
this chapter. 

Accommodation Required. — ^T wo rooms is the least 
number required for even a small centre, and three are 
desirable. For a centre where more than some ten or 
twelve children attend at a time, three rooms must be 
regarded as essential. Sanitary accommodation and a 
place for keeping perambulators are also necessary. 
One of the rooms will serve as a waiting-room where the 
mothers sit on their arrival. There should be some 
method of warming the waiting and other rooms in 
winter, and adequate ventilation should not be forgotten. 
Another room is needed as a private consultation room 
for the doctor who will see the infants one by one. The 
children are weighed, either in the consultation room or 
in the third room, according as is preferred by the 
doctor. In any case, the remaining room should be 


available for undressing the children before they are seen 
by the doctor. The consultation room should have a 
good light, and this requisite will probably determine 
which room shall be allotted for this purpose. 

White overalls or coats should be worn by all the 
workers, and hats should be removed. Some form of 
receptacle which can be easily washed should be pro- 
vided for the clothes of each child so that there is no 
mixing of garments. Only a few children will be in the 
undressing room at once, some of them waiting for the 
consultation and others dressing after it is over. In 
some cases the consultations are held in the morning, 
but the majority of centres are open in the afternoon. 
At many centres, especially where the agency respons- 
ible is voluntary, it is not unusual to provide tea and a 
bun or biscuit at a small charge. 

Weighing. — It is essential that the children should be 
undressed for weighing and for the medical examina- 
tion. No accurate figure for the weight can be obtained 
if some or all of the garments are left on. It is argued 
by those who approve this method that the mothers 
bring the children up in the same clothes on each occasion 
80 that the error in weight due to the clothing is always 
the same. It is difficult to see how such a statement 
can be made seriously, since not only must the clothing 
change from week to week, but it should be different in 
winter and summer, and, moreover, as the child grows, 
it will need new and larger garments. There is no virtue 
in weighing as such ; its object is to note the progress of 
the child. It is especially valuable when the progress is 
slow or absent, when an ounce or two either way may be 
of much importance in deciding the advice to be given. 
Care should be taken with the weighing and a good 
balance used. The Post Office balance, which only 
weighs to within about four or more ounces, especially 
when the child is moving in the scale pan, is of little 
or no value for this purpose. Weighing which is care- 


less or inaccurate may as well be omitted. There is more 
difficulty in accurate weighing than might be supposed, 
and most people have a sort of personal equation which 
makes their reading rather different from that of others ; 
wherever possible, therefore, the same person should 
weigh on each occasion. 

The undressing also enables the state and nature of 
the clothing to be seen. The kind of clothing provided 
is frequently quite unsuitable, and may be improved 
by appropriate assistance and advice. Moreover the 
mother will be more careful in regard to cleanliness if 
she knows the child is to be undressed. It is sometimes 
argued that there is little to be gained if the cleanliness 
is for one day in the week only, but at least one clean 
day is better than no clean day and may be the fore- 
runner of others. 

The scale pan should hold a piece of wool or a blanket 
to keep the infant from feeling the cold of the metal, and 
a fresh piece of clean paper over the blanket should be 
used for each child. The blanket or wool must be of 
known weight. 

Record Cards. — Various forms of medical records 
are kept at child welfare centres. The object of the 
record is to provide information as to the condition of 
the child at its first attendance, together with such 
details as are necessary of its place in the family and 
home conditions, and to which additions may be made 
on each occasion of the child's attendance. When the 
centre is large, a system of card indexuig will be neces- 
sary, and this will be kept either in the waiting-room or 
in some further adjoining room. On the arrival of the 
mother the record is found, or a fresh one prepared if it 
is a first attendance, and placed ready for the doctor, 
and handed to him or her when the infant concerned 
is in theJ[consuJtation room. It is usual, also, to give 
the mother a card on which the baby's weight is entered 
and notes of the instructions she has been given. 


(Samples of such record cards are shown in Appendix I.) 
The information obtained by the visitor on her visits 
after the notification of the birth may be used for the 
details of home conditions, etc., and any alteration in 
these noted. 

The record cards should not be fuller than is really 
necessary. A card that requires much time and leaves 
space for all manner of details will, in all probability, 
not be filled up as carefully as one which, being less 
elaborate, can be properly dealt with in the time avail- 
able. It is not necessary that any more than the salient 
features should be recorded in ordinary cases. 

The record cards should be available (or copies of 
them) for the school medical ofiicer when the child 
attends school. It is the only means whereby an 
accurate record of the child's previous health history 
can be obtained. The record card would, for example, 
show at a glance the ailments which it had suffered 
from including the infectious diseases and would furnish 
valuable data for research on all these points. 

It will evidently take some years before such records 
are generally available, but their importance is very 
great and no time should be lost in getting the whole 
system of records in hand. 

Frequency of Attendance. — The medical officer de- 
cides the frequency of attendance at the consultation. 
A good arrangement is for the date of the next attend- 
ance for consultation to be written on the record and 
on the mother's card. It may be that the doctor will 
wish to see the child every week for the first two or 
three weeks of its attendance, and that unless some 
unforeseen difficulty occurs, the visits can then be 
lengthened to fortnightly, or later, monthly, or, as the 
child gets older, quarterly visits. It is found, however, 
that in many cases it is advisable to allow the mothers 
to attend as frequently as they wish on the special 
afternoon, as it conduces to attendance on the consulta- 


tion days. The baby can be weighed by the workers 
but not sent to the consultation room unless some 
untoward event has supervened which renders this 

Clothing. — Child welfare work has brought into 
prominence the question of clothing, but it is doubtful 
whether the full importance of proper clothing is even 
now properly appreciated. While details can be sought 
for in the text-books on infant hygiene, a few remarks 
upon this matter will hardly be out of place here. It 
looks almost as if there were no age at which clothing 
is more oppressive than during the early months, or 
perhaps years, of childhood. The unfortunate infant 
is obliged to wear exactly what its mother or nurse 
thinks would be good for it, or ornamental for the out- 
side garments. The child wants freedom to stretch 
its arms and legs, freedom of movement for its chest and 
body, but custom has prescribed that the clothing of 
the infant shall do its utmost to hamper the poor Uttle 
mite in its efforts to grow healthy and to develop on 
the lines intended by nature. 

To take the undergarments first. Who has not seen 
the terrible article known as a binder ? Some bandage is 
necessary until the child has parted from the remains of 
its umbilical cord, but not afterwards. The practice of 
days gone by still persists in many homes of sewing a 

Siece of flannel as tightly as it is possible round the ab- 
omen of the miserable infant. Sometimes the binder 
is so tight that the child literally cries with the pain, as is 
evinced by the sudden cessation of the cry when the 
binder is released. Even if this degree of duress is 
avoided the binder is uncomfortable, and usually works 
its way up towards the chest where, becoming crumpled 
up in layers over the lower part, it effectively prevents 
the expansion of the chest m breathing. If it should 
remain in the position intended by the nurse or mother, 
it tends to produce internal discomfort, and is by many 


regarded as one of the causes of constipation in infants. 
If the binder be knitted, as is now sometimes the case, 
the wool may shrink, and the binder become hard and 
excessively tight for the infant. But custom has pre- 
scribed it, and, tight or loose, comfortable or uncom- 
fortable, it is placed on the often stoutly resisting child. 

Then there is still in some parts, the horrible little 
cotton shirt with short sleeves, which is followed by 
another binder, stiff and starched this time, and extend- 
ing over the greater part of the distance between the 
arms and legs of the unfortunate infant. Binders have 
nothing to recommend them, and should be omitted 
from the infant's wardrobe. The writer remembers 
attending a consultation where needles and cotton were 
actually provided by the centre for the sewing up of 
these instruments of torture after the weighing. 

Then there is the flannelette petticoat with cahco 
bodice, as soon as the child is a little older, which, owing 
to its lack of warmth, has to be duphcated and reduph- 
cated until sometimes as many as four or more of these 
garments are piled on the child to keep it warm. The 
outer and outdoor clothes are little better. The long 
frock with heavy embroidery and frills, stretching over 
the toes and weighing them down, the short sleeve 
tied up with ribbon, the thick peUsse, the padded bonnet 
without any ventilation, and the woollen veil, which 
effectually negatives any benefit the child might obtain 
from being in the fresh air, should all be dropped in 
favour of more hygienic garments. The ideas of many 
on the subject of clothing are still tainted with suggestions 
of the dark ages, and that not alone among the poorer 

The child wants to be kept warm in winter by a few 
woollen garments. A woollen vest with long sleeves, a 
longer woollen garment, extending so as to enclose the 
feet, and an upper garment of reasonable length and 
weight will suffice for indoor wear. Napkins should be 



of soft material, such as Turkish towelling, and should be 
washed between each use. In summer the clothes 
should be modified to the change in temperature. One 
cause of trouble for the poor mother is the custom of 
wearing long clothes up to about two months old, when 
a fresh set of short clothes has to be provided. The now 
prevalent fashion of so called three-quarter length 
garments can be used from birth onwards imtil the child 
begins to walk, by which time they will, in all proba- 
biUty, be worn out. Unfortunately the clothing is 
provided before the child is bom, and the mother is 
reluctant and often unable to change it. Good progress 
has, however, been made with the mothers who attend 
many of the centres. Model garments should always 
be on view, and the workers be prepared to show the 
mothers how the garments can be made. Where classes 
are held, some mothers will be able to attend them, but 
many will be unable to do so. These last can be aided 
by helping them to cut out or to put the pieces together. 
In other centres, paper patterns are sold for Id. 
Again, rolls of flannel, etc., may be bought at wholesale 
prices, and sold in quantities for single garments at 
cost price. There are many methods in practice for 
helping the mothers with the clothing of the infant, 
and all are valuable. At some centres the mothers can 
pay in small sums weekly, and then purchase material as 
they need it. 

p.- Talks or Lectures. — These are also not infrequently 
arranged, and may be given by the doctor or by some of 
the visitors. Long talks should be avoided. Probably 
ten to fifteen minutes is as long as it is possible to retain 
the attention of most mothers who attend, whose 
schooldays are long past, and in whom the power of 
concentrated attention is small. Opinions vary con- 
siderably as to the value of lectures. 

Classes. — It is often diflGicult for a mother with one or 
more young children to attend classes. These are more 


easily attended by mothers with children at school. A 
large attendance is seldom obtained, but even if only a 
small number of mothers attend, these may be able to 
help those who are unable to do so. 

Various classes are held, often differing at the same 
centre year by year. They will include cooking, laundry, 
mending, cutting-out, sewing, knitting, millinery, etc. 

In some districts a fully trained Domestic Economy 
teacher is provided, who devotes her whole time to this 


The Centre {oontinued) 

In addition to the phases of work ah:eady described, 
there are a number of other branches of assistance with 
which it is very desirable that centres, in at any rate 
large populous areas, should be associated, although not 
necessarily carried on at the centre. Such are ante- 
natal work, arrangements for securing aid from the 
various social agencies, and of food or milk for neces- 
sitous cases of mother and children, and also of dental 
care, the importance of which is difficult to over- 
estimate. Further forms of aid are dealt with in the 
next chapter. 

Ante-natal Work. — ^As the development of child 
welfare proceeded, it became clear that it was not 
sufficient to deal with the child after birth. The health 
of the mother during pregnancy, and the conditions 
obtaining at the birth are known to exercise all-im- 
portant effects on the future health of the infant. The 
conditions present at the birth of the child fall essentially 
within the purview of the doctor or midwife, since they 
alone are authorised to attend and take charge of con- 
finements. These conditions can, however, be modi- 
fied by care before the time of confinement. There are 
many matters calling for attention. The mother's 
health, the presence or absence of ailments, whether 
directly connected with the pregnancy or not, her habits 
of life, her food, clothing, exercise, etc. : the provision 


for confinement, both for herself and for the baby : the 
baby's clothes, sleeping place, etc. In fact, as in the 
case of child welfare work, ante-natal work has both 
preventive and curative aspects. 

Every mother should be placed in the path of health, 
both for herself and for her infant. Many are ignorant, 
and do not know what they should do, nor how to do 
it. They are usually very glad of advice and assistance, 
if tactfully given by the right person. While many 
women do not need treatment at all during their preg- 
nancies, it can hardly be denied that a general medical 
examination is advisable. Often some slight chronic 
trouble is present, which may produce trouble or 
difl&culty during or after labour. Among these are 
cardiac disease, bronchitis,, bad teeth, chronic septic 
trouble in any part, etc. Such matters clearly demand 
medical care, but the patient does not always know of 
their presence and may not regard them as deserving 
of any attention. In such a case the condition will 
ordinarily not be discovered until it is too late to avoid 
the consequences of neglect. 

When a doctor is engaged to attend the case, a com- 
plete routine examination is not usual unless the mother 
complains of some ailment. 

If a midwife is engaged she must refer cases of 
ailments to a doctor, but she will find it difificult to 
persuade many mothers of the desirabihty of the trouble 
and expense of the medical examination unless there is 
some definite complaint. Power to pay doctors' fees in 
cases of pregnancy was conferred by the Maternity and 
Child Welfare Act, but so far, no special fee has been 
fixed, and arrangements for providing it are, at present, 
very limited indeed. The task of advising the mother 
how to secure adequate and suitable provision for the 
confinement should be, and is regarded as, the duty of 
the midwife in those cases where one is engaged. But, 
in the present conditions (see Chap. XVII) many mid- 


wives cannot afford the time which would be required, 
and, moreover, the untrained midwives are usually not 
in a position to offer such advice. 

These considerations have led to the demand for ante- 
natal care at the child welfare centres, and this is pro- 
vided at a considerable number of them. 

Great care should be taken, however, to co-operate 
with the doctors and midwives practising in the dis- 
trict. In some districts where co-operation has been 
established from the first, the centre has proved of 
great benefit to all concerned. The midwives have felt 
that they were receiving due consideration, and that 
they were in no danger of losing their cases. Unfor- 
tunately, these important considerations have not always 
been borne sufl&ciently clearly in mind at all centres, 
and much opposition has been aroused among the 
doctors and the midwives of the district. 

Ante-natal work has undoubtedly been brought into 
prominence by the efforts of the centres who are in a 
position to see the disastrous effects of the neglect of 
ante-natal care in all its branches, and there is no more 
vital need for child welfare than adequate care of the 
mother before, during, and immediately after child- 
birth. While the centre has a place in this, and can do 
most valuable work, it is a late arrival in the field of 
midwifery work, and more good will probably result 
by endeavours to improve existing agencies than by 
trying to take over a part of their work. The centres 
feel that they can achieve more in a short time than is 
likely to be the case if the ante-natal work is left to be 
gradually undertaken by midwives and hospitals. It is 
true that the progress with these agencies taken over the 
whole country is bound to be slow, but it is doubtful 
whether the process of, as it were, superposing ante- 
natal work over a structure which, although imperfect, 
already exists, and should be made to bear it, will fulfil 
the purpose intended. Ultimately the work must be 


done by doctors and midwives, either in the home or 
in hospitals, as a part of the medical service of the 
country. There is room for all, but the shortest cut 
on a steep path is not always the quickest. Much 
technical matter is bound up with ante-natal work, 
certain aspects of which will be dealt with in connection 
with the work of midwives. 

The Provision of Dinners for Mothers. — At most 
centres in a poor district need will arise among a few 
mothers for the provision of a good meal. Such pro- 
vision, when made, is confined to expectant or nursing 
mothers, and is designed to secure a healthy child, and, 
later, to maintain breast-feeding. Some people dis- 
approve altogether of this provision on the ground that 
the aid is purely temporary, and that, in many cases, 
the mother could perfectly well afford to provide her- 
self with adequate food, but that she is either too 
ignorant of cooking or generally unwilHng to exert 
herself, and it would be better to persuade her to 
look after herself than to feed her. Doubtless these 
criticisms are just, but there are cases where the mother 
is too depressed, or too ignorant to be able to manage 
for herself during pregnancy. Very careful investiga- 
tion should, however, be given to each case lest the 
system should degenerate into mere charity. 

In some places the dinners are provided elsewhere 
than at the centre, or arrangements are made with a 
cheap restaurant or the invalid kitchen to feed special 
cases. The beneficial effect secured by providing a 
good meal, even four times a week, is surprising, and 
may enable breast-feeding to be continued for the full 
nine months. ^ 

^ Although adequate food conduces to breast-feeding, too much 
food appears to have the contrary effect. Women of the better- 
to-do classes who are persuaded of the importance of eating largely 
to maintain the mammary secretion, do not obtain successful 
results. The process is a natural one, and an ordinary diet should 
be pursued as far as possible. The motlier should eat sufficient, 


The meal usually consists of either a good thick soup 
with vegetables, and perhaps suet dumphng, or meat, 
with potatoes and vegetables, followed by a good plain 
pudding, sometimes with stewed fruit. The menu will 
vary greatly with the opportunities for buying food. 
The sum paid by the mother is generally about 50 per 
cent, of the cost price, and may be much less — a few 
dinners are often given free. Under the Maternity and 
Child Welfare Act of 1918, money may be obtained 
from the rates for the provision of food for mothers. 
It is usual to require a certificate, either from the 
medical officer of the centre or from an experienced 
health visitor, for admission to the dinners. 

The Provision of Milk. — There is probably no branch 
of child welfare work which has attracted more atten- 
tion than the provision of milk forartificially-fedchildren. 
The dishke of hunger is a primitive instinct, and the 
appeal for food finds an echo in the hearts of most 
people. How much more is this the case when the only 
food required is milk, as is the case with young children 
in the early months of life. 

The provision of milk was one of the main early 
aspects of the child welfare naovement, and only after 
many years was the fallacy appreciated. There were 
two errors — one, the most important, concerned the 
whole question of artificial feeding. There was a wide- 
spread belief that the human species was becoming effete 
and unable to provide breast-milk, so that artificial 
feeding was necessary. The experience gained during 
recent years has shown that nearly all women can 
breast-feed their babies if they are taught how to manage 
the feeding. The mammary gland is still capable 
of function, but it has often been asked to put up with 
treatment which defeated the object in hand. Probably 
the two-hourly feeds, still, alas ! advocated by many, 

but over-feeding hnB been found to luivo a dotrimental offoot on 
the Bupply of broiut-milk. 


have done more than anything else to discourage breast- 
feeding. The milk depot encouraged the belief that 
artificial feeding was necessary and eased the path to 
the mother. It undoubtedly tended to discourage 
breast-feeding — there was ordinarily no medical super- 
vision, and the mother not unnaturally thought that as 
the milk was specially provided it must be good, and 
she might be spared the trouble of breast-feeding, 
seeing that all was ready prepared for her. 

The other main source of error arose from the tendency 
to regard the feeding as the most essential need for the 
well-being of the infant. While it is, of course, true 
that the child will die if it is not fed, it may also die, 
even when receiving sufficient food, if its general con- 
dition and surroundings are unsatisfactory. Milk 
depots, originally believed to be a prime factor in 
child welfare, have been found to be only an accessory 

The early milk depots provided pasteurised milk in 
bottles of different sizes according to the age of the child. 
There were standard mixtures and standard quantities 
to the feed. The depot cannot make up special feeds 
for each child, the labour and time required are pro- 
hibitive in cost. Yet the more experience is gained 
with regard to artificial infant feeding, the more clearly 
does it appear that each child must be considered in- 
dividually. There is no standard amount or standard 
mixture which is exactly suitable for children of different 
ages or of different weight. The six or seven stock 
mixtures of the milk depot of fixed amount, and ar- 
ranged for a definite number of feeds in the day, are not 

The milk depot cannot be run without considerable 
expenditure of money. The mother cannot ordinarily 
afford to pay more than the cost price of the milk itself. 
In addition to the initial outlay on plant, there is the 
cost of labour, of the fuel for_^the pasteurisation, the 


continuous wear and breakage of bottles in the process 
of heating, the rent of the depot, etc. 

Even when worked with regard to economy, the milk 
depot is an expensive matter, and the money available 
would be better employed in other branches of child 
welfare work. 

The expense of the milk depots, and the fact that they 
did not appear to be producing the efEect anticipated, 
prevented their development on a large scale in this 
country. Also, it was realised that very few mothers 
were able or willing to send regularly to the depot for the 
milk, and that, at intervals, the child was fed as the 
mother might decide, from milk obtained at any dairy. 
The milk depot is not educative. It does not teach the 
mother how to feed her baby even artificially, and rather 
discourages breast-feeding, unless proper medical super- 
vision is arranged for. 

If cow's milk is supplied in any form, it should be 
on the advice of a doctor only, and should only be given 
on the condition that the child is brought up regularly 
for medical supervision. 

The pasteurised milk depot gradually gave way to 
dried milk as this commodity was placed on the market. 
At the present time only a very few places provide 
any other form of milk, and the majority of centres 
make some arrangement for the provision of such 

This is not the place to embark upon a discussion on 
the merits or demerits of dried milk as a food for infants, 
but a few remarks may not be out of place. Usually the 
milk is purchased wholesale and sold at cost price retail. 
A considerable saving to the mother is thus effected. 
The use of dried milk has now been very large for a 
number of years, and much experience in its use has 
been gained. Yet, although there have been many years 
of experience on the question of artificial feeding for 
infants, the details are still the subject of warm dis- 


cussion, and no agreed system is advocated by those 

There is probably no one subject in medical literature 
which has formed the subject of more discussion than 
milk in its various aspects. One school of thought 
pressed for the use of raw milk, and another for the use 
of sterilised milk, and so on. Now we have the discussion 
on dried milk as against other forms of cow's milk. It 
is hardly likely that any one form of artificial feeding 
will find acceptance with all advocates, just because the 
whole procedure is artificial. 

A breast-fed baby has, as it were, greater license. 
It can take more milk than it really wants, and with- 
in reasonable limits no harm results. Its digestive 
organs can deal with varying quantities of the natural 
food. But cow's milk, of which the constituents, 
while similar in type to those of human milk, are yet 
different in composition, requires much more care if the 
digestive organs are not to be upset. Over-feeding with 
cow's milk will lead to a degree of indigestion which is 
not found in breast-fed babies, and ""a host of other 
troubles follow in its wake. It^has^lbeen justly said 
that a baby lives on its alimentary canal in the early 
months of life. If the functions of that complicated 
organ are deranged, the whole organism suffers, and 
may die as a result. 

There is a school of thought that regards all dried 
food as unsatisfactory, because certain so-called " vital " 
properties are believed to be destroyed in the process of 
drying, or even of the heating in pasteurisation. This 
remark at once leads to the much vexed question of the 
extent of heat employed in heating milk, and on this 
matter there is great confusion in the literature, both of 
thought and of language. It may therefore be well to 
set out the true position. Pasteurisation means that 
the milk, or whatever substance is under consideration, 
is heated to a temperature considerably below boiling 


point, and 180^ Fahrenheit is the usual figure given in 
this country. As soon as the temperature is reached, or 
at most, after two minutes at this temperature, the milk 
is rapidly cooled by the use of cold or of iced water, and 
should subsequently be kept at a low temperature until 
it is used. 

In conversation the term " pasteurisation " is 
frequently used to denote any form of heating milk where 
a low temperature is subsequently applied. For in- 
stance, it is applied where the milk is raised practically 
to boiling point, and even when such a temperature is 
maintained for prolonged periods. 

Then again, the term " sterilisation " is applied when 
really pasteurisation is meant. Many people call milk 
which has been heated in any way " sterilised," whereas 
this term should only be applied to milk which has really 
been rendered sterile. Sterility is difficult to obtain with 
milk, and a temperature above boiling point will be re- 
quired. Again the term " boiled " is often used without 
any comment as to the method used, that is, whether 
boiled over the flame or in a jacketed pan, and without 
any reference to the length of time of boiling. All these 
matters make a difEerence. 

There is no advantage at all in heating milk beyond 
the temperature required for pasteurisation. The 
object of heating is to kill certain germs which may be 
harmful. These are killed by pasteurisation, and the 
other varieties, while reduced in number, are not all 
killed even by boiling. The pathogenic germs reach 
the milk from two main sources, the cow herself and the 
workers on the farm or dairy. A great many cows in 
this country are suffering from tuberculosis, and the 
bacilli are passed out in the milk. Although with pre- 
cautions much can be done in a good dairy farm towards 
eliminating this disease, it is hardly possible with our 
present methods to state definitely that any given 
specimen of milk contains no tubercle bacilli. Again, 


cows suffer from inflammation of the udder, and in 
such cases streptococci are found in the milk which 
may cause bad sore throats in those driuking it. Both 
varieties of bacteria may be passed into the milk when 
there is no obvious disease in the cow when examined 
by the veterinary surgeon. 

Then again, the milkers, or those handling the milk at 
later stages of its transit, may be carriers of disease, such 
as tuberculosis, enteric fever, or diphtheria, and outbreaks 
of scarlet fever have been traced to the milk supply. 
Many possible sources of infection can be removed almost 
entirely with due care, but it will probably not be possible 
to be certain that there is at no time a source of infection 
among the workers. The dangers from the cow are 
even more real, because infection with tuberculosis 
is widely spread in many herds. 

Some heating of the milk is essential in order to remove 
the risk of harmful bacteria. No milk should be taken 
raw. But, as already explained, pasteurisation if 
properly carried out is sufficient. The heating should 
be carried out after the milk has been put in the recep- 
tacle from which it will be taken by the individual and 
not before. It is sufficient to heat the receptacle in a 
vessel of water, and to allow the water to boil for two or 
three minutes. The milk does not reach the temperature 
of the water. The receptacle should then be plunged 
into cold water, and remain there until required for use. 

There has been, and still is, much discussion as to the 
detrimental effect of heating milk. Certain substances 
known as " vitamines " are necessary for the mainten- 
ance of health. Their absence may cause infantile 
scurvy and possibly rickets. These substances, which 
are present in small amounts in milk, are stated to be 
destroyed by heating. But here much confusion has 
been caused by the lack of definition in regard to the 
length of time the milk has been heated. In some of the 
experimental work undertaken, the milk was heated 


for an hour at boiling point, and was then found to have 
suffered the loss of some of the vitamine-content. But, 
if pasteurised, it appears that no appreciable loss is 
incurred. There is nothing to be gained by heating 
beyond this point, so that from this aspect, pasteurised 
milk can be safely used ; nor is the food value of the 
milk reduced — in fact, heated milk is found to be more 
easily digested than raw milk. 

In the processes of drying milk may, for a few seconds, 
be exposed to a temperature somewhat above that used 
in pasteurisation. The special methods employed 
reduce the time of heating, and it ^has not]|yet been 
shown that the vitamine-content' of dried ;^milk is 
reduced appreciably below that of the original milk. 
It is not unlikely that some small loss may occur. 
Practical experience has, however, shown that dried 
milk can be used for infants with excellent results, if 
proper precautions are taken. Over-feeding with dried 
milk, and its subsequent digestive disturbances, seem 
to occur more readily than with pasteurised milk. But 
this may be due to the instructions on the tins of the 
milk, which often advise a great deal too much milk and 
too many feeds. Although the mother may be told to 
follow the doctor's instructions, and not those on the 
tin, it does not follow that she will do so, and many 
women think that the more a child can be got to take, 
the better it will be. Hence unfortunate results may 
occur owing to the excess of zeal. It is so easy just to 
add a little more of the powder, and the directions 
printed on the tin will appeal to the mother. 

Some doctors advise that fruit juice, of one kind or 
another, should be taken with dried milk after the 
first few months. It is very doubtful how far this is 
necessary, but many children who are fed artificiallv 
seem to improve more rapidly with the addition of fruit 
juice or of a small amount of fruit puree after about 
six months of age. 


The report issued by the Local Government Board * 
on the use of dried milk, shows that dried milk properly- 
used is a satisfactory artificial food for infants. It 
cannot, however, be too clearly stated that no known 
artificial food can adequately replace natural feeding. 

Dried milk has the advantage of being comparatively 
sterile, and of keeping for some time after the tin is 
opened, also only the amount needed at each feed is 
used, and there is no waste involved. 

Milk is undoubtedly a necessity for children up to 
about eight or nine months of age, but the milk should 
be that of its own species, namely, mother's milk. It 
is probable that breast-feeding is now more common than 
it was a few years ago, but there are still too many chil- 
dren who are fed artificially : for these cow's milk in some 
form is necessary. After the age of eight or nine months 
milk gradually ceases to be a necessity as the child's 
organs become able to digest other food. Its value as a 
foodstuff decreases, and the child needs variety of food. 
Milk is not a foodstuff of great value for adults. No 
other species of young take milk after weaning, and 
there is no real need whatever for the human infant to 
do so. We have got accustomed to the idea of milk, and 
to regard it as a necessity for children and for cooking. 
But at the present price of milk especially, much better 
food value can be obtained with other less costly foods. 
The statements as to the immense quantities of milk 
often said to be necessary for children are quite 

Then again, so much is talked of the value of milk 
for expectant and nursing mothers. There is no special 
value in milk for mothers ; any other good nourishing 
dietary will do equally well, or better. It sometimes 
seems that people are under the impression that milk 
taken by the mother is utilised directly by the mammary 

^ Report tu the Local Government Board by F. J. Coutts, M.D. 
(Food Reports, No. 24). 


gland for its secretion, and mothers are advised to drink 
milk half an hour before they feed their babies. Milk, 
like all other good foodstiiffs, is broken down into 
the simple substances, and the mammary secretion, 
like the other secretions, requires building up from 
simple bodies. 

A number of local authorities are preparing to spend 
considerable sums on the provision of milk for mothers 
and infants. It is well known that infant mortality 
was low during the worst cotton strike, when, although 
poverty was great, the mothers stayed at home and 
breast-fed their babies, and the same effect is stated 
to have been produced in Germany during the recent 
war. It is hoped that local authorities will pause 
before spending large sums of money on milk. There 
is no doubt the money could be better employed. 

The following letter, which appeared in The Times on 
3rd September 1919, is of interest in this connection: — 

"Milk for Children 

" To the Editor of ' The Times ' 

"Sir, — You wiU remember that during the war we 
were accused of murdering German babies through the 
reduction of milk supply attributable to some extent 
to our blockade. The current number of the Eevue 
Internationale de la Croix Rouge shows that infant 
mortality in Germany decreased, especially in the big 
towns. In 1914, 15*1 per cent, of infants died within 
the first year in the whole of Germany ; in 1916, 148 
only. In the towns of over 15,000 inhabitants the 
figures were 14*1 and 13-3 per cent. In Switzerland in 
towns of over 10,000 inhabitants the fall was from 9 9 
to 6-9 per cent. Here follows the explanation : — 

'* ' Comment expliquer ce fait curieux outrement que 
par la p6nurie du lait en tomps de guerre et I'augmen- 


tation par compensation de Tallaitment maternel.' 
The whole article is written to prove the greater life- 
chance of the mother-fed infant. It looks as if the 
coming scarcity of milk in England may induce English 
mothers to nurse their own children (if they can), and 
80 give them a better start in life, besides diminishing 
our present mortaUty rate of 10-7. — Yours faithfully, 


Dental Work. — This is undertaken at a fair number 
of centres, and in other places some arrangement is 
made, either with a local dentist, or with a school clinic 
or hospital for providing such treatment for cases sent 
on from the centre. 

The vital importance of sound, clean teeth is being 
increasingly recognised among all classes. The utterly 
deplorable state of the mouth of large numbers of 
people requires remedying before we can hope to be- 
come a healthy nation. A decaying tooth is, in fact, 
an open sore, the exudation from which, being con- 
tinually mixed with saliva, is for the most part swal- 
lowed, but also infects all parts of the mouth and lips 
and fouls the breath. Bad teeth are a source of great 
danger to the possessor. Small, or in bad cases, large 
doses of toxic material are being continually absorbed, 
and afiect the condition of the whole body. Waller ^ 
has shown that the removal of bad teeth in a nursing 
mother effects a tremendous improvement in the growth 
of the child, and increase"* the mammary secretion. 
It is horrible to contemplate the effect on an infant 
of being frequently kissed by a mother whose very 
breath is infective, and most people who have had to 
do with child welfare work will recall cases where the 
dummy teat, in itself a vicious thing, has been rendered 
actively harmful by being previously sucked by a 
mother with a foul mouth. The mother has got so 
' Lancet, November 1916. 



accustomed to tlie condition of her mouth that its dis- 
advantage to the infant does not occur to her. 

Dental care should be regarded as an important 
branch of ante-natal work. The old idea that it was 
dangerous to give gas to a pregnant woman has been 
found by Waller ^ not to be correct, and the bad teeth 
constitute a risk to the mother of Septic complications 
at the confinement. Any septic spot will be liable 
to cause trouble after a confinement, and bad teeth 
have been found to be the cause of death in a number 
of cases. In addition, there is the great improvement 
of health which follows on the removal, either by ex- 
traction or stopping, of the decaying spots. 

The provision of dentures will be necessary in a 
number of cases, and may require a great deal of trouble. 
It is usual to endeavour to obtain a part of the money 
at least from the mother herself ; there are also, in 
some places, voluntary funds, and the centre, if neces- 
sary, will find some of the cost, and can receive a part 
repayment from State funds. 

The cost of establishing a separate dental depart- 
ment is considerable, owing to the special fittings and 
instruments required. In London a few of the large 
centres have opened dental clinics for their patients, 
which are also used by the London County Council for 
school children, the Council paying a per capita grant 
for the use of the clinic. 

It is difiicult to overrate the value of dental care, 
and the increasing number of clinics is a hopeful sign. 

The number of school children under school age 
whose teeth require attention is lamentable. ^ Bad 
first teeth affect the second teeth, so that the former 
should be carefully attended to. 

The recent work by Mrs. Mellanby ^ shows that the 
growing teeth are affected by rickets, in which con- 

* Loc. cit. ' Of. figures in Appendix II. 

■ Lancet, December 1918. 


dition the enamel is not laid down properly, and the 
underlying dentine is thus deprived of its protecting 
coat. The condition also adversely affects the de- 
velopment of the jaw. 

Lawson Dick ^ found evidence of rickets in the teeth 
of 52 per cent, out of 586 rickety children examined 
by him in the course of school medical inspection. 

Mellanby^ has shown that an unsuitable dietary 
is a primary factor in producing rickets and badly 
formed teeth in young dogs, and there is every reason 
to believe that this is applicable to children. 

Social and Charitable Work. — Child welfare work is 
not a form of charity, and this should never be lost sight 
of. In the work of the centre there must inevitably be 
cases where various forms of charitable aid will be 
required. But such aid should not be given by the 
centre itself. Those who work at the centre should 
be aware of the various charitable agencies which 
exist, and should use their efforts to secure assistance 
from the appropriate agency. The agency concerned 
will have proper channels of information and of assist- 
ance, which should be made use of. 

Co-operation and co-ordination of effort should be 
aimed at in all cases. The charitable agencies will 
have cases they wish to refer to the centres, just as 
the centre has cases to refer to the charitable agency. 
If each organisation tries to do the work of other bodies 
there will be overlapping of effort, waste of time and 
money, and, which is not less important, the work 
will probably be less well done, owing to the absence 
of special knowledge on certain points. 

The responsible workers at every centre should regard 
it as a part of their duty to be acquainted with the 
work of the various agencies for social and charitable 

* Proc. Roy. Soc. Medicine, 1916, vol. ix. pp. 83-9. 

* Report on the Accessory Food Factors by the Medical Research 
CJommittee, 1919. 


work of the district : they should go further and make 
themselves personally acquainted with those who are 
carrying out the work. Personal acquaintance removes 
many sources of difficulty and prevents many troubles, 
A little time devoted to a personal interview with 
the responsible agent of the society in question about 
a special case is time well spent. 

Doubtless, with the expected passing away of the 
Poor Law and the presumable increase in the powers 
of the local authority for material assistance, there 
will be a greater tendency to dispense such aid at 
centres for child welfare. It will be a tragedy if 
centres which have the opportunity for doing such 
admirable preventive work come to be regarded as 
organisations for the distribution of material relief. 


The Centre {continued) 

The varied activities which have been described in the 
preceding chapters would, by common consent, be 
described as falling under the heading of preventive 
work. That is to say, the measures are all directed 
towards the maintenance of health and the prevention 
of disease. There are in addition several branches of 
work which are being increasingly undertaken at child 
welfare centres which are less directly preventive in 
their scope. 

Such measures trench closely on curative medicine. 
The dividing line from the work of some centres and 
that of certain phases of work at some hospitals is fine 
and in many instances difficult to draw. 

The several branches to which reference is made are : 

1. The provision of drugs and beds for children. 

2. The provision of treatment for children from two 
to five years of age. 

3. The provision of facilities for treatment of maternity 

There is much divergence, both of opinion and 
practice, in regard to the provision of drugs and of 
arrangement for treatment generally at child welfare 
centres. The point is one of great importance and it 
will be well to consider the position fairly fully. 

1. The Provision of Drugs.— There can be little 

doubt that the provision of treatment in any form 

was not contemplated when the infant welfare move- 



ment was first started. It is, however, clear that no 
movement of such a kind could continue long without 
meeting the numerous cases of ill-health which are too 
frequent among children of (apparently) all countries. 
With the greatest care, illness is unavoidable among 
a number of infants, and the clientele of the infant 
consultation soon had sick children for whom they 
sought advice. It was necessary either to send the 
child to a hospital or to a private doctor, or conversely, 
to treat the child at the centre. This last method was 
recognised as being ordinarily undesirable on many 
grounds. The local doctors and the hospitals objected 
strongly as causing overlapping of effort, and also 
because except in cases of minor ailments better 
facilities for treatment were available at the hospital 
than at the centre, and the local doctors very naturally 
objected on the ground of the treatment at the centre 
being free. They contended, very justly, that many of 
those attending the centre could well afiord a doctor's fee, 
and that the cases should be referred to their doctor, 
or, if too poor, to the local hospital if there was one. 

Another point which does not always receive the 
weight it deserves is the fact that the centres are only 
open on certain days and hours, and a sick child may 
need care within those specified times. The mother 
must then (unless it should occur on the day she is 
due at the centre) take the child to another doctor or 
to the hospital. Objections are raised, not unnaturally, 
at taking over from another practitioner a case which 
has become acute. The objection is not mitigated 
by employing a local practitioner as the medical officer 
to the centre, who can then see acute cases at either 
his or their own home. This is open to the serious 
charge of taking patients away from their own doctor, 
since many of those who attend the centre will have 
their family doctor, who may not be the medical 
ofl&cer of the centre. Cases where the ailment is liable 


to need attention before the next consultation should 
in no case be treated at a consultation. 

On the other hand, the centres feel that it is not 
satisfactory to send children from the centre to the 
hospital or doctor for minor ailments. Very often the 
child requires some treatment, but the mother has not 
considered it worth while to pay for the doctor or to 
wait some hours, as she may have to do, at the hospital. 
Not infrequently, therefore, the child remains untreated 
and progress is impeded. Clearly, it seems simpler 
for the centre to undertake the treatment of such 
cases. Again, it is argued that the local doctor may 
not pay much attention to slight matters which the 
centre has detected. Compared with the troubles with 
which he is dealing among his patients, the little trouble 
of the infant, not severe in itself but requiring attention, 
seems hardly worth while to treat. While it is said 
that the general practitioner is not interested in the 
minor ailments of children, he or she is not likely to 
become more interested if these cases are not referred 
to him or her. 

Troubles due to errors of dietary have always been 
regarded as falling within the work of the centre, since 
for the most part they can be cured by alterations in the 
dietary and other points of general advice. It is usually 
agreed that sodium citrate, dusting powders, single 
doses of aperients and one or two other similar sub- 
stances may be regarded as legitimate for child welfare • 
centres. But general cases of sickness requiring drugs 
should not be treated at the centre. 

There is also another subtler objection but one which 
is nevertheless real. If drugs are given freely at a centre, 
there is a strong tendency to give them in cases which 
do not really need them, and which, if due care were 
exercised, could be dealt with at an earlier stage by 
hygienic methods. This last is vastly more educative 
for the mother and better for the child, but it is greatly 


to be feared that, if drugs are allowed, there will be a 
tendency to turn to them. The centre would thus 
approximate to the out-patient department of a 
hospital and have travelled far away from the original 
cause of its estabUshment. If, after due consideration, 
treatment is encouraged at the centres, it should be 
administered on separate days and only in cases of 
minor ailments. 

Then there are rickety children requiring treatment 
over long periods with expensive material such as cod 
liver oil. For the most part doctors are not anxious to 
have many of these cases, as they need a good deal of 
advice, and the mothers are frequently unable to pay 
either the fees for the visits or the cost of the drugs and 
food prescribed. It is common for centres to buy cod 
liver oil in large quantities and also malt, and to sell 
these at cost price to those children for whom it is pre- 
scribed by the doctor at the centre. 

A useful practice has developed for the summer at 
certain centres where there is a garden. Certain cases 
of dietetic troubles, or other forms of minor ailments 
which may be considered suitable, are put in the garden 
during the day. They are brought by their mothers in 
the morning. The mother can also come to feed if the 
child is on the breast. Excellent results have been 
obtained by this method, especially in the case of babies 
who have developed the habit of screaming or who are 
suffering from too frequent or unsatisfactory feeding. 

The improvement obtained in many of these cases is 
quite remarkable, and the mother is able to see for 
herself that only simple measures are being adopted. 
The nervous, irritable infant calms down under regular 
feeding and open air and obtains the sleep it needs. 

There seems no doubt that a number of troubles arise 
in infants from nervous conditions, and it is stated that 
these have been increased since the beginning of the war. 
Very often there is no organic trouble at all, but the child 


needs quiet and good care in order to establish its health 
and ensure satisfactory progress. Hospital treatment 
is not required but the home care is not sufficient. 

Then there are cases of more severe nutritional dis- 
orders. Such ailments should certainly not be treated 
at centres unless special provision is made. This has 
been recognised, and a number of centres are now making 
special arrangements for deaUng with some of the babies 
who attend the centre but fall sick. Every child welfare 
centre has cases on its books of children who are not 
acutely ill but are perhaps suffering from some nutri- 
tional disturbance which does not yield to the mother's 
care, requiring more attention than she can give. These 
cases often need only a short period of adequate care in 
order to be re-started on a satisfactory basis. To meet 
this need wards have been opened and a nursing staff 
provided to look after babies, while the advice is given 
by the doctor of the centre. These wards are varpngly 
called " observation wards," " babies' homes " or 
" baby wards," and it is not intended that they should 
take cases of illness which require full hospital care. 

The beds for the purpose above described, whether in 
summer in the garden or in a ward, are undoubtedly of 
great value, but the whole question of beds in connection 
with child welfare centres needs to be approached with 
caution. So long as they are kept for cases which do 
not require and perhaps are not suitable for hospital 
treatment, no objection on general grounds need be 
raised, but, on the contrary, the beds are valuable. 

If, however, they should be allowed to become merely 
small hospitals, the effect would be disastrous. Small 
hospitals are either extravagant, both of skilled service 
and of money, or they are of inferior quality. If acute 
cases are admitted there should be a resident medical 
staff and this is costly for a few beds only. 

The centres were estabhshed for preventive work, and 
while it is no doubt difficult to draw a hard and fast line 


of distinction between the different spheres of work, as 
a whole purely curative work should be discouraged at 
child welfare centres. At the moment the position is 
compHcated by the wholly insufficient provision of 
hospital beds for children all over the country. Such 
accommodation as exists is already severely taxed to pro- 
vide for the acute cases of illness even in districts where 
in-patient care is available at all. The Ministry of 
Health makes grants towards the maintenance of beds 
connected with the centres, but not towards the beds in 
a hospital, unless the beds are reserved by arrangement 
with the local authority for the use of patients sent 
in through one or other of the channels of child welfare 
work recognised by the authority. 

The problem is not easy — voluntary funds at present 
supply the upkeep of practically all hospitals, other 
than Poor Law infirmaries, and until recently,^ the rates 
might not be drawn upon for sick children outside the 
Poor Law. The Maternity and Child Welfare Act of 
1918 gives power to build and maintain maternity 
hospitals, but the expenditure of considerable sums of 
money on children's hospitals has not so far been very 
favourably viewed by the Local Government Board. 
This branch of work is directly curative and should be 
undertaken in connection with any adequate organisa- 
tion for medical services generally, rather than as an 
extension of child welfare work. In the meantime, a 
few of the larger local authorities are giving grants 
towards the maintenance of children's beds in connec- 
tion with centres on the understanding that a number of 
them are reserved for patients from the municipal 
centres for child welfare. These beds are usually re- 
served for cases of alimentary disturbances. 

It may be necessary for a little while to allow or even 

' Power to spend money on hospital beds for cliildren under 
Ave waa conferred by the Maternity and Child Welfare Act of 1918. 
See Appendix III. 


to encourage somewhat the provision of treatment at 
the centres. But the aim should be to provide proper 
facilities under the recognised auspices for dealing with 
sick children, namely, the hospitals and local doctors, 
and to reserve the centres for preventive work. 

Human nature will probably always have a greater 
attraction towards cure than towards prevention. It 
is impossible to tell at once what may have been pre- 
vented, but curative measures show results in a short 
time. The ideal is that there should be^-no ailments 
needing cure. At the present time there is a great deal 
of illness among children, and if treatment were definitely 
taken on by the centres they would soon be flooded 
with curative work and the preventive work would be 
crowded out. In some centres this is already the case. 
The question is not simple and involves many issues, 
but no effort should be spared to keep the preventive 
aspect prominently forward as the main object of the 

It is difficult to say how far treatment is undertaken 
at centres throughout the country, but there is reason 
to believe that the tendency has been growing of recent 
years and that care is necessary to prevent an undue de- 
velopment in this direction. Even if a medical service 
should be established, under which provision were to be 
made for the treatment of all persons, it is greatly to be 
hoped that the preventive aspect of the child welfare 
centre would be clearly maintained. 

The above remarks apply specially to children under 
two years of age. After the child reaches three years 
the nature of its ailments approximates more to those 
of older children and are of a different nature. 

2. Provision of Treatment of Children from two 
to five years of age. — The child welfare movement, 
when it first began, was directed to the prevention of 
mortality among children under one year of age. Gradu- 
ally it was realised that much valuable work was undone 


by the absence of provision for the care of the child at 
later periods. The physical condition of children attend- 
ing school had been attracting attention about the same 
time. It was realised that much of the educational 
opportunities offered could not be utilised adequately by 
the children on account of their ill-health. In 1908 power 
was given to the local education authorities to provide 
for the medical inspection of school children, and several 
authorities soon got to work. The amount of ill-health 
among the children which was then revealed was very 
appalling. The children examined on entering school 
were found to be suffering from one or more ailments, in 
nearly two- thirds of all cases. Some of them had prob- 
ably been subject to the trouble for a considerable time 
before they entered school, and it was recognised that 
they should have received treatment at an earlier date. 
At first treatment was not provided by the local educa- 
tion authorities, but it was found if the parents were 
merely advised to take the child to a doctor or hospital 
even if arrangements were made by the authority, that 
very frequently no action was taken by them. 

Hence, special clinics for treating common ailments 
have been growing in number under the auspices of 
the local education authorities. Such clinics usually 
make provision for dealing with enlarged tonsils and 
adenoid growths, with defective vision, minor troubles 
of the eyes, discharging ears, minor skin troubles, and 
in many cases a dental clinic is arranged. 

The truly alarming amount of ill - health among 
entrants brings out very clearly the urgent need for 
dealing with these children before they enter school. 
This should be undertaken as a branch of child welfare 

After about the age of two years the child's ailments 
approximate to those of older children and at three 
years of age there is little distinction between theirs and 
those of children entering school. 


Medical supervision should be exercised right up to 
school age, and home visitation is usually necessary as 
well. When the child attends school it can be reached 
with ease, but it is more difl&cult with the younger 
children who are at home. The mothers often will not 
bring them up to the centre and home visits will be re- 
quired for the detection of ill- health. These visits will 
be paid by the visitor, who will urge the mother to attend 
the centre if the child is not progressing favourably. 
There should ordinarily be special days, as already men- 
tioned, for children of this age, unless only the medical 
inspection is undertaken on that day. 

The question of treatment for children of this age 
assumes a different aspect from that among the younger 
children. Greater facilities are required which are 
frequently not available in a doctor's surgery, nor 
in the homes of the patient. It is no use referring 
many of these cases to the local doctors on these grounds, 
and the local hospital often does not undertake work of 
this type. Again there is the difficulty of fee. The 
mother may be unable or unwilling to pay the fee for 
such treatment by the local practitioner, even though 
the fee be in reality moderate. Further, if all these 
cases were to attend the surgery, the doctor would be 
overburdened with them. At present in the majority 
of instances they are not treated until they enter 

The need for provision of treatment for these children 
is now being recognised and in some places provision 
is made, but the work among children from two to five 
years of age lags sadly behind in its development as 
compared with that of children under two and over five. 

It will evidently be waste of effort to provide separate 
climes for children imder school age, and so far as it is 
at all possible arrangements should be made for the 
children to be treated at the school clinics. Hitherto 
some difiiculty has been experienced owing to the fact 


that [the child welfare work has been undertaken 
by the Public Health Department, and the work 
among school children has been under the local 
education authority. Further, in some areas, the 
authority may vary and the two branches of work be 
under two separate authorities. Now that the Ministry 
of Health is responsible for the health of school children, 
these difficulties should be minimised, and it is to be 
hoped that a great extension of work among children 
under school age will result. 

As the provision of medical service for the whole 
country improves, the work, both among children of 
school age and under school age, will no doubt be 
brought in to form part of the services provided. 

While it is not possible here to deal at length with the 
ailments of these children, it will be of interest to show 
something of the prevalence of the various troubles. 
The figures of the ailments found on medical inspection 
among the children of London in 1917 are given in 
Appendix H, and further information can be obtained 
by reference to the very interesting reports pubHshed 
each year by the Medical Officer of the Board of Educa- 
tion, Sir George Newman, where the figures are given 
in greater detail for the whole country. 

3. The Provision of Treatment for Maternity 
Cases. — There is no need at the present time to empha- 
sise the necessity for the care of the mother both before 
and after the birth of the child. The early work 
undertaken in connection with the medical examina- 
tion of expectant mothers showed that there was a 
great deal more ill-health among women than had 
been believed. Ante-natal work, as already described 
at the centres, does not necessarily imply the treat- 
ment of ailments. Such treatment, however, must 
be arranged for somewhere if the best results are to be 
obtained from the work. The same difficulties arise as 
in the question of treatment among the children, only 


the case is more urgent. The health of the mother 
affects that of the unborn infant, and there is only a 
limited period within which to take action. 

The facilities at present available for the treatment 
of minor ailments is as insufficient as in the case of 
infants. Some doctors are interested in this branch 
of work, and do much good among their patients, and 
also take trouble with cases sent on to them from mid- 
wives. Often the treatment most needed is merely rest 
and general care, which may be the most difficult of 
all for the mother to secure. 

In some large towns homes of rest for such cases 
are now available, but in many instances the absence 
of the mother from home involves grave difficulties. 

Pregnancy should not be regarded as a pathological 
condition, and the general improvement in the con- 
ditions of life among the poorer classes which the war 
has brought about should materially assist in reducing 
the amount of illness among the poorer mothers. The 
treatment of the present ill-health among them is, 
however, of great importance. 

The provision of treatment at a centre involves some 
compUcations. Every woman must be attended at 
the confinement by either a doctor or a midwife, and 
ordinarily she will be sent up to the centre by whichever 
of these she has booked with. There will, of course, be 
a few cases which attend on their own account, and 
before they have booked. The centre should, however, 
induce them at once to book with either a doctor or a 
midwife, or, it may be, with the out-patient midwifery 
department of a hospital. 

But this, in effect, removes the woman from the care 
of the centre, unless the doctor or midwife agrees that 
she shall continue to attend. 

It is impossible to say if there is any practice on 
the question of treatment, as each centre doing ante- 
natal work will make its own regulations. Also com- 


paratively little of this work is carried out as compared 
with the infant welfare work. 

The provision of facilities for confinement is not 
ordinarily undertaken by the centre. A few employ 
a midwife to attend the cases, especially if there is a 
shortage of midwives in the district. Some local 
authorities are now working small maternity hospitals 
with great success, but usually separate from the 

The question of the provision of maternity beds is 
discussed in connection with the midwifery service in 

Chap. xvin. 

Generally the position is that the centres are fully 
aUve to the need for the treatment of ante-natal cases, 
but the difficulties are great, both on the grounds above 
mentioned, and also because it is difficult to get hold 
of the mothers, many of whom do not realise that they 
need care, and do not, therefore, make any effort to 
apply for it. As the women themselves get to appreci- 
ate the need for improvement in their own health the 
nearer will the problem be towards its solution. 


The Organisation of Child Welfare Work in 
Urban Areas. 

In the preceding chapters the work of the visitor under 
the Notification of Births Acts, and the activities at 
or connected with a centre, have been considered, 
reference being made occasionally to the machinery 
for carrying out the work. If the full benefit is to be 
obtained without overlapping and unnecessary expense, 
a great deal of forethought and watchfulness is required 
on the part of those who are responsible. 

In a few areas, notably in MetropoUtan boroughs, 
the greater part of the work is carried out by voluntary 
agencies. In the provinces generally the amount of 
responsible voluntary work is relatively small as com- 
pared with that of the local authority.^ There can, 
however, be no doubt that the responsibility for the 
work, for its organisation, economical working, and 
avoidance of overlapping, rests everywhere on the 
local authority. The refusal to undertake their 
responsibihties does not remove the duty. 

In this chapter the general organisation alone will 
be dealt with, the part played in it by voluntary 
agencies being considered afterwards. 

* Recent figures obtained by courtesy of the Ministry of Health 
show that out of a total of 1583 centres througliout England and 
Wales 675 are worked by voluntary agencies. Of the 675, 153 are 
in the MetropoUtan area. Oi the 908 centres worked by local 
authorities, 622 are in the hands of municipalities, and 286 in the se 
of county councils. 



The Notification of Births Act of 1907 might, subject 
to the consent of the Local Government Board, be 
adopted by any local authority. It was found in 
practice that individual rural districts could not, 
other than in rare cases, work the Act without undue 
expense and difficulty. For the most part, at the 
present time, the work in rural districts, and in the 
smaller urban districts, is in the hands of the county 
councils. In this chapter the work in county boroughs, 
boroughs and urban districts of populations of not 
less than 20,000 is considered. In rural districts, 
the sparseness of the population renders a different 
organisation necessary. 

The history of Local Government in this country forms 
a most interesting study, but one which is entirely 
beyond the scope of this work, except in so far as it 
refers to child welfare work. In order to make the 
descriptions given in this book intelligible. Chaps. 
XXII to XXV have been added, which supply, it is 
believed, sufficient information to make the position com- 
prehensible to the student of child welfare. Here only 
a few preliminary remarks are made. The whole coun- 
try^ is divided up into sanitary areas whose boun- 
daries are clearly defined. Each of these areas has its 
own council, consisting of a fixed number of persons who 
are elected by ballot by those inhabitants who are 
entitled to votes. In boroughs, the mayor is the chair- 
man of the council, and other councils elect their 
" chairman." The councils are divided into sub- 
committees wliich deal with the detailed work falling 
upon the council. This differs according to the powers 
placed in the hands of the council concerned. All 
sanitary authorities have powers to deal with sanitation, 
and the detailed work is carried out by a public health 
committee, subject to the approval of the council.'* 

' England and Wales alono are under consideration in this book. 
* Of. p. 210 for information as to the Maternity and Oliild Welfare 


While the town clerk or the clerk to the district council 
is the officer appointed to carry out the decisions of 
the council, the medical officer of health carries out 
certain duties under the direction of the council and of 
its public health committee. 

The staff of visitors are appointed by the public 
health committee, and work under the direction of the 
medical officer of health as a part of the staff of his 

The number of health visitors required will vary with 
the number of births, and with the amount of other work 
required to be done by the staff. The medical officer 
of health divides the area to be worked into districts, 
and allots a visitor to each district, the size of the 
district varying with its character. Centres should be 
arranged so as to be convenient for each district. 
Whether one centre can serve the districts of two 
health visitors will depend upon the situation and 
character of the districts. It is found that only a pro- 
portion of all the infants visited are brought to the 
centre. With the development of the work, the pro- 
portion is showing a well-marked increase. Some few 
years ago 25 per cent, of all infants visited was a high 
figure for entries at the centre. The more usual figure 
was 15-20 per cent. Now, in a fair number of towns, 
the proportion has risen, and 33 per cent., or about one- 
third of all infants visited, may be found on the registers 
of the centres. In a few districts the figures reach 
50 per cent, of all cases visited. 

It has been proved by experience that, allowing 
for departures from the district and irregularity of 
attendance, from 125-150 infants in the year is as 
large a number as can reasonably be dealt with for 
one consultation a week. This does not allow of 
more than an average of ten medical consultations per 

Ooramittee, now a Statutory Committee under the Maternity and 
Child Welfare Act of 1918. 


infant, or about thirty consultations per consultation 
session, throughout the year. For one medical officer, 
thirty patients per half-day is almost too many for each 
to receive proper attention. At many centres a con- 
siderably larger number of children are sent through to 
the doctor at each session. But there are limits to the 
endurance of a medical officer, and it is generally ad- 
m tted that twenty-five is really as many as can be 
dealt with adequately. There is no point whatever in 
merely passing infants through the consultation room 
so rapidly that there is no time for a proper considera- 
tion of each case. At some centres the children are 
sent up to the doctor whenever they are brought up, 
with the result that many of them have simply to be 
told to go on as before. It is waste of the doctor's time 
to send children who are progressing favourably to the 
doctor every week or fortnight. The intervals of the 
visits should be determined by the medical officer, and 
adhered to unless some untoward occurrence has 

Supposing that not more than 150 infants be reckoned 
for each weekly consultation session at the centre, 
and that an attendance of 33 per cent, of all infants 
visited is allowed for, then each centre can deal with 
not more than 450 births, or with about the numbers 
allotted to a full-time visitor taking infants up to one 
year only. 

It has been already explained that both visiting and 
attendance at the centre should be carried on up to 
school age, and that on this basis only about 250 bii ths 
per annum at the outside can be allotted to each full- 
time visitor. Also that extra consultations should be 
arranged for the older children. Roughly, in a district 
of about 450 births, there should be at least one consulta- 
tion day per week for infants, and one for young chil- 
dren under school age. The demarcation line is vary- 
ingly fixed between one and three years of age. In 


such a district, it would be necessary to employ two 
whole-time visitors to carry out the child welfare work 
only.^ These two visitors should then both attend the 
two sessions, and each be in the consultation room when 
the infants from their districts are being seen by the 
doctor. Each visitor should be able to spare two half- 
days a week for work at the centre, and the value of 
this arrangement has already been dwelt upon, both 
from the point of view of the mother and the visitor 

When work is being started in new districts it would 
be unnecessary to allow for the attendances of so high a 
percentage of infants visited. Probably for the first 
two years it suffices to allow for the attendance of about 
15 per cent, of all infants visited. Also, the older 
children, not having been regularly visited at an earlier 
age, would not attend in large numbers. If the visitors 
are doing other branches of work, which occupy about 
half of their time, then the number of infants and of 
older children they can visit will be correspondingly 
reduced. This may render their attendance at the 
centre more difficult, since the centre may then serve 
four visitors' districts, without any increase in the num- 
ber of children under school age. The difficulty can be 
met in various ways, and, although it may not always be 
easy, it is of the utmost importance that the visitor 
should attend the consultation when the infants she 
visits are being seen, and every effort should be made to 
secure this. 

It is found that it is usually difficult or sometimes 
impossible for a mother to come to a centre which is 
more than half a mile away from her home. This in- 
volves the establishment of centres not more than a mile 
apart. The population and the number of births in 

1 This standard of staff is very rarely reached as yet, and would 
doubtless be regarded as excessive by many. It is, however, 
necessary it the best work is to be done. 


any area of half a mile radius will differ in different 
towns, and in different parts of the same town. Hence, 
evidently, the number of centres required, and the 
number of visitors' districts each centre can serve, will 
differ, and no generaUsation as to areas can be made. 
Where the district is congested, the centre can be open 
five days in the week, and two medical officers can 
attend on the same occasion, if necessary. This clearly 
involves the provision of sufficiently large premises in 
order to avoid overcrowding and delay at the centre. 

The transport facihties available in the district will 
also affect the position and number of the centres 
required. Tramways being cheap, accessible, and the 
service frequent, the mothers may be able to attend 
from rather greater distances, although the expense 
and difficulty of carrying by tram several small children 
who cannot be left alone at home must not be forgotten. 

Again, it is not necessary that all the activities de- 
scribed should be available at each centre. Mothers 
who are able to attend classes can probably go 
farther than for the consultations. They will usually 
attend one course in the winter or they may attend 
alternate winters, and so on. The medical consultation 
is the central activity of the centre, and this should be 
provided at all the centres. Other activities can be 
distributed in other centres. Thus, in Cleveland, Ohio, 
the sub-centres are open in the morning for medical 
consultations. Any case requiring treatment is sent 
on at once to one of the main centres, where, if neces- 
sary, it is referred to the children's hospital for in-patient 
or out-patient care ; the hospital is regarded as part of 
the general scheme, but a distinct branch of the work. 

Each town will need to have its own scheme, adapted 
to suit its distribution of population, tramways, etc. 

Staff of the Centre. — The essential staff of the centre 
will bo the medical officer and the health visitor. If 
the centre is very large, it is often found necessary to 


appoint a superintendent of the centre. The super- 
intendent will be responsible, under the medical officer of 
health and the consultation officer, for all the arrange- 
ments of the centre ; for the adequate keeping of the 
record cards, and probably for some home visiting of 
special cases. The precise duties will differ in different 
places. When the numbers attending are very great 
a clerk may also be employed to assist the superin- 

Further, there is a need for other workers, who need 
not be highly trained, and who will take charge of the 
" toddlers," talk to the mothers, help with the classes, 
etc. These duties can well be carried out by con- 
scientious voluntary workers, although at many centres 
such help is not available. 

At some centres in the largest towns, arrangements 
are made for consultant physicians for maternity cases. 
Again, where ante-natal care is undertaken, this may 
or may not be placed in the hands of the medical 
officer of the infant consultation. Great latitude must 
be allowed, and the intention in this book is merely to 
show the general lines upon which this work is carried 


The Combined Duties of a Visitor in the 


Reference has already been made in various places 
to other forms of work which a visitor may be 
called upon to undertake. When infant welfare work 
was commenced, it was usual to place the duties upon 
the female sanitary staff, who did yeoman's work in a 
large number of districts. As the work grew it became 
impossible for the existing staff to carry out both 
phases of the work, and gradually official visitors were 
appointed as infant visitors, usually termed health 
visitors. This latter term at present may or may not 
include infant visiting, depending entirely upon the 
nature of the health visiting work allotted to the worker. 

It has already been explained that all local sanitary 
authorities were given power to adopt the Notification 
of Births Act of 1907, and to undertake work for child 
welfare at the cost of the rates by the Act of 1915. 
In order to understand how other duties have fallen 
to the health visitor some digression is necessary. 

The Education Act of 1902 made all counties, county 

boroughs,^ and boroughs having populations of 10,000 and 

over, and urban districts havmg populations of 20,000 

and over, education authorities under the Act. All rural 

districts or urban districts, and boroughs of insufficient 

population to become education authorities in 1902, 

come imder the county for educational purposes. When 

' For further iniormation, see Chap. XXII. 


the medical inspection of school children was intro- 
duced in 1908, power to carry on the work was given 
to all the education authorities. The development 
of the inspection led to the following up or home visita- 
tion of many of the children. It was speedily realised 
that it would be more economical, and altogether more 
generally satisfactory, to combine the work of following 
up with the infant visitation. 

The same visitor would visit for children of all ages, 
and time of travelling, and therefore cost be reduced. 
Hence many local education authorities place the 
school work upon the infant visitor. Some districts 
keep the work and workers quite separate, and there 
is a growing tendency in this direction in the large towns. 

In 1911, with the introduction of the Insurance Act, 
and the tuberculosis work in connection with it, 
further home visitation was required. The duty of 
carrying out this work was placed upon the county 
boroughs and the counties only, so that the non-county 
boroughs and urban districts who are education 
authorities were not directly affected by the Act in 
this particular. A fair proportion of county boroughs 
have a special staff for the tuberculosis work, but a 
considerable number place this work also upon the 
health visitor. Some of the county councils make 
arrangements with the boroughs and urban districts, 
whereby their health visiting staff undertakes the 
tuberculosis visiting on behalf of the county. 

In 1913 the Mental Deficiency Act was passed, but 
its execution has been delayed owing to the war. The 
duties are in the hands of county councils and county 
borough councils. This requires home visiting for 
many of the cases, and the work has already, in some 
districts, been placed on the health visitors. 

The work which may fall to a health visitor may, 
therefore, comprise infant visiting, an attendance at 
the centre, including work among children up to school 


age, the following up after school medical inspection, 
and, in addition, tuberculosis visiting among both 
sexes and all ages, also possibly, the work among 
mentally defective persons. School and tuberculosis 
work usually involve attendances at the inspection 
and dispensary respectively, so that a good deal of 
time is taken up by these branches of work. There 
is great advantage in the combination of duties for a 
health visitor. A change of work keeps her interest 
from flagging, and some branches of work are less 
exacting than others. Infant visiting is, as a whole, 
the most exacting, because the visitor has no assist- 
ance at her first visit, or after, unless the children attend 
the centre. In school and tuberculosis work the 
diagnosis and lines of action are laid down by the 
medical ofiicer. 

In a district with 500 births a year it may be esti- 
mated roughly that, allowing for the visitation of infants 
up to one year of age only, the school work will take 
about as much time as the infant work, and the tuber- 
culosis work about one- seventh of the whole time 
required for the other two services. 

The work of a health visitor may, therefore, be very 
varied. In some districts other special forms of work 
are undertaken and laid upon the health visitor. 

In a few places the health visitors act as inspectors 
of midwives. This is considered fully in later chapters. 

The compulsory notification of measles cases which 
came into operation in the year 1916, and was recently 
rescinded, brought into prominence the need for visita- 
tion of notified cases. This duty is not infrequently 
laid upon the health visitor, but since it involves other 
considerations, it will be dealt with in relation to 
infectious diseases in Chap. XXI. 


Child Welfare Work in County Areas 

In the preceding chapter the work of a child welfare 
visitor in an urban area was dealt with : where the 
population is more sparse the work partakes of other 
aspects. In towns with proper adjustment of districts 
there should be no appreciable loss of time in getting 
about from one home to another. When the popula- 
tion is so small that the visitor has an area of a number 
of square miles allotted to her, the loss of time involved 
in travelling becomes a feature which must be seriously 

It will clearly make for economy if the visitor is 
given as many duties in her district as possible, so as 
to bring about the greatest concentration of work. 

It is uneconomical for rural districts to undertake 
their own infant \^elfare work because they can 
ordinarily only give the visitor the one duty. The 
county council, which is responsible for the school 
work and the tuberculosis work, must send a visitor 
into the rural district area for these purposes. Thus 
two visitors incur loss of time in travelling over the 
same area for different purposes. Such loss of time 
means increased expenditure on the work, and at the 
present time the tendency is for the rural work to be 
undertaken by the county council. 

The county council will appoint the visitors, and in 
most cases where whole-time visitors are employed 
the several duties of infants, school, and tuberculosis 


work are placed upon the same visitor. It is difficult 
for those who are not well acquainted with the conditions 
of rural England and Wales to realise the time required 
to get about some of the areas. The train services 
on the small local lines are usually infrequent and 
inconvenient. The main roads are usually good, but 
the byroads are often very bad in the winter. Some 
of the remoter houses have no road near them, and are 
a mile or more away from other houses. 

In each county area ^ there will be small towns 
forming centres with populations of sufficient size to 
form centres of work for the visitors. Around these 
will be the rural areas with populations gathered here 
and there into villages of varying sizes, but with one or 
more houses some distance removed from any village. 
Arrangements have to be made for the visitation of all the 
individuals falhng under any of the schemes for the health 
of the population of the county. It is usual, if possible, 
to place one or more visitors in a town, and allot to them 
the surrounding areas as districts. The number of dis- 
tricts will depend upon the population and other con- 
siderations. BicycUng is almost essential for a visitor 
in a rural area — the distances are too great for walking, 
and in a few cases only will the railway afford ade- 
quate faciUties for transit. It is of great advantage for a 
visitor to have a nucleus of homes near her dwelling. 
She can often do visiting near by when, owing to bad 
weather or other circumstances, she might be unable 
to visit in distant places. 

It will be impossible for her to visit on any definite 
date after the birth other than occasionally, since she 
will arrange her work so as to spend a whole or part of a 
day in the same district, visiting infants, school children 
and tuberculosis cases in the same day, together with 

' The administrative county for purpoHos of the work of the 
oonnty coiincil, consists of the geographical coxmty minus the 
oounty lK>roughs ; of. Chap. XXII. 


any other visits connected with such other duties as 
may be laid upon her. 

The county councils are not sanitary authorities, and 
cannot deal with sanitary defects, such as defective 
sanitation, insujG&cient water supply, etc., which must 
be carried out by the local sanitary authority, namely, 
the urban or rural district councils, and arrangements for 
co-operation between the two councils on this side of the 
work are essential. It is of the utmost importance that 
the visitor employed by the county should be on per- 
fectly friendly terms with the responsible people of the 
council or councils of her district, even though such 
councils may sometimes appear to her to be irritating and 
slow in their methods. The officials of the smaller 
councils are hampered by the poverty of the council 
and by the vested interests with which the councillors 
may be closely connected. 

The number of births which can be visited by a county 
health visitor will depend upon the position of the pop- 
ulation, whether aggregated or entirely scattered, and 
upon the time taken by her other duties. It is not 
possible to require the same number of visits per annum 
to each case in the country as in the towns, since the 
average time taken per visit, allowing for the journey, 
will be greatly in excess of that in a town. Some 
visits may take almost the whole morning or afternoon 
if the house is far removed from neighbours. 

In some counties there will be districts where very 
little rural work will fall to the lot of the visitor who may 
be located in a town or large village which requires her 
whole time. Arrangements for centres are clearly more 
difficult than in urban areas, the mothers have farther to 
come, and if they can find means of conveyance or can 
walk, they will hardly be able to attend as frequently as 
in the towns — also it will be more difficult to obtain the 
services of a medical officer. A great variety of arrange- 
ments are made. In some cases, a doctor will attend 


monthly, and the visitor fortnightly, to weigh babies, and 
give advice in the absence of the doctor. Or the county 
council may employ a medical officer to visit the centres 
in the county on different days, either weekly or fort- 
nightly according to the work required. 

When the district is so sparsely populated that only 
some five or six mothers can attend at a session, it is 
doubtful whether the cost of establishing a centre is 
justified. A good deal will depend upon what charge is 
made for the rooms, and on existing local conditions 

The arrangements for visiting, record cards, etc., do 
not difier from those already described for the urban 

The above description of work appUes in a fair number 
of counties. But it is now necessary to consider a wholly 
different system operating in some of the counties, and 
which, in order to understand it, requires a clear idea of 
the work of county and district nursing associations. 

It is now many years since certain well-disposed per- 
sons in different villages or towns inaugurated bodies 
known as nursing associations. The object of the 
associations was to provide nursing for the sick poor 
who were unable either to obtain any nursing aid, 
or whose relations were not sufficiently skilled to give 
the aid required. These persons banded themselves 
together with the object of providing funds to pay for the 
services of a nurse. The greater part of the nurse's 
salary was paid by the association, a small part only 
being provided by the very low fee charged for the 
services of the nurse. 

The nurse was under the control of a committee for all 
matters other than professional, when she was required to 
work under the doctor called in by the people concerned. 

Many associations also provided midwifery aid for 
the district, and it then became necessary to employ a 
uursc who was able to undertake this branch of the work. 


This last item is more usually required in rural areas than 
in small towns. Here independent midwives are prob- 
ably available, whereas in rural areas they are unable to 
obtain a liveUhood with midwifery work alone. 

The formation of district nursing associations spread 
fairly widely, especiallyin some counties, but it is evident 
that their existence depended entirely upon the financial 
position and inclination of the better-to-do inhabitants. 
Hence, the district nursing associations were formed 
most readily in towns, and less readily in the sparsely 
populated areas, where, however, the need for them is 
often greatest. 

The area which can be served by a nurse who is pro- 
vided with a bicycle in a rural district is about 2-2 i 
miles in radius, so that, in order to cover the whole of a 
county, a very considerable number of district nursing 
associations are necessary. In every county there are 
districts where no provision can be made without an 
almost prohibitive expenditure of money, and even at the 
present time, only two or three counties have a service 
which extends over the whole area. 

The district nursing associations soon began to ex- 
perience difficulties — the first was finding the nurse — 
some nursing training was required, and a midwifery 
training if this work was to be undertaken. The cost of 
training was considerable, and comparatively few women 
were prepared to defray the cost of their own training, 
especially in view of the relatively small salary which 
could ordinarily be offered. 

Then, if a nurse was ill or needed a hohday, it was diffi- 
cult to find some one to replace her. These and other 
considerations were effective in producing another body 
— the county nursing association — which, while not 
itself undertaking any nursing or midwifery work, 
could act as a more influential central body. 

County nursing associations have been formed in 
nearly all counties, and they have been the means of 


providing or obtaining funds for the training of women 
as nurse-midwives, and of assisting district nursing 
associations in their other difficulties. They have 
usually secured help from the education committee of 
the county council for training, but have generally 
also raised considerable sums of money privately for 
this purpose. 

Assistance was only provided for those district 
nursing associations who became affiliated to the 
county nursing association, and who paid an affiliation 
fee. In every county there have been and are a certain 
number of district nursing associations worked mainly 
by individuals who prefer to retain their private patron- 
age, in spite of difficulties, rather than fall in with any 
general scheme. It should be remembered that the 
existence of a county nursing association does not 
imply that the whole county is provided with nurse- 
midwives, but only that a central association exists 
for such district nursing associations as are in being, 
but it may be that considerable portions of the county 
are entirely without provision of this nature. 

The gradual rise in standard which has been continu- 
ally demanded in both nursing and midwifery, since the 
beginning of the present century, together with the 
cost of living, which had already risen appreciably 
before the war, have added very materially to the cost 
of working the district nursing associations. 

Moreover, the increasing tendency towards State or 
rate-aided schemes has made many people less inclined 
to subscribe to services such as that of district nursing 
associations. The financial difficulties of the associa- 
tions have therefore become progressively more pressing 
of recent years. Simultaneously with this pressure, 
the work undertaken by the county councils for child 
welfare, school work, and tuberculosis work, has been 
developing, and the district nursing associations, 
powerfully backed by the county nursing associations, 


have in nearly every case pressed the county councils 
to employ their nurses for this work, and to subsidise 
them for this purpose. 

Theoretically, this scheme appears to have everything 
to commend it, but further investigation is necessary 
to see how far such an arrangement may or may not 
be desirable. The primary difficulties arise in connec- 
tion with administration, and the qualifications of the 
majority of the nurseb. 

The nurses in the less populous areas have, for the 
most part, received a year's training only, which in- 
cluded approximately six months' district nursing and 
six months" midwifery training. They have received 
no training in child hygiene, or in school or tuberculosis 
work. Many of them, although excellent workers, 
find the keeping of records difficult, and are unable to 
organise their work satisfactorily without assistance. 
Administratively, several difficulties arise — the nurses 
are in the employ of the local associations, and are 
expected to carry out instructions received from the 
associations. If, however, the county council is to 
pay for the time and work of the nurses for special 
purposes, evidently the nurse must accept and carry 
out instructions from the county medical officer of 
health who is responsible for the carrying out of the 
county work in those branches. 

A^ain, the nurses, if employed by the county for 
special purposes, must either report to the county 
medical officer of health, or must be visited by some 
one deputed by him and authorised by the council to 
see that the work is being satisfactorily performed. 
County nursing associations nearly always employ a 
superintendent, who is a fully-trained nurse, with 
midwifery training and of experience in both branches. 
This lady inspects the work of the nurses who are em- 
ployed by affiliated district nursing associations. If 
the county councils, who are the authority for super- 



vising the midwives in the county, appoint separate 
inspectors of midwives, a dual system of inspection is 
established, and difficulty is almost certain to arise.^ 

Many county councils therefore employ the super- 
intendent of the county nursing association as their 
inspector of midwives under existing circumstances. 

Whenever possible, however, medical women should 
be employed as inspectors of midwives. 

If the county council decide to employ the county 
nursing association, provision should be made for 
instruction of the nurses in infant hygiene, and in any 
other duties which may be laid upon them. 

There are undoubted advantages in allowing the 
village nurse- midwives ^ to undertake the child welfare 
and other county work. The nurse is known to, and 
knows, practically every one in the district, and it is 
held that the mothers prefer being visited by some one 
who lives in the village. Then, also, there is great 
economy in travelhng expenses and in the whole cost 
of the work. Against these advantages it has to be 
remembered that the whole-time visitor is usually very 
much better trained and more efficient, and, if the nurses 
are to be employed, some arrangement for their training 
in infant hygiene should be made. Also, the visitor soon 
becomes known in the district where she works. When 
the nurse's district is large, or the area populous, she will 
hardly have time to attend properly to the pubUc health 
work, and there may be periods when illness is prevalent, 
and a few heavy cases of sickness may render it almost 

^ The piisition of the county and the superintendent of the 
county nursing association is discussed further in connection with 
the inspection of midwives on pp. 131 et aeq. 

* A village nurfle-midwifo is a woman who has been trained as a 
midwife with some experience in nursing. The Queen Victorin 
Jubilee Institute for Nurses trains fully-trained nursos in midwifery 
and in Hcho<d work if the nurse wishcH to undcrtiko district work. 
She then becomes a " Queen's " Nurse. 0)uiity nursing associa- 
tions can be affiliated to the Institute, and obtain privileges with 
corresponding obligations, 


impossible for ter to attend to any other duties than her 

An important point arises on the financial side. 
Owing to the increasing difl&culty of maintaining the 
nurse-midwives, it may be impossible to retain their 
services at all unless the grants for public health work 
are available. In such cases the county council is faced 
with the risk of allowing a valuable service to disappear 
for lack of funds. There is power to subsidise the nurse 
for her midwifery out of county funds, but such a 
subsidy might have to be unreasonably large in order 
to maintain the midwife, as compared with the number 
of midwifery cases attended by her, whereas, with the 
grant for the special services, a smaller subsidy would 
be sufficient. 

The training of the village nurse-midwife for nursing 
is a much-debated question, and one which will no 
doubt receive attention in the near future. At present, 
it hardly falls within the range of child welfare work, 
although it is easy to show that sick-nursing and child 
welfare work are closely connected. As it involves 
the whole question of nursing in all its branches, and 
raises large administrative and economic questions, it 
will not be considered here. 

In counties where there is a county nursing associa- 
tion, the council may employ the nurses in the villages, 
and may provide whole-time visitors in the towns 
and in those districts where, owing to the sparseness 
of the population, it has not been possible to provide 
nursing aid. In the now few counties where there is 
no county nursing association the county will provide 
its own service of visitors, but not the village nurse- 
midwife, since there are no powers to provide a nursing 
service out of the rates, although it seems probable 
that this power must soon be given. 

If, and when these powers are given it is not unlikely 
that the work of the county nursing associations, 


being thereby placed on an altogether different basis, 
may show a tendency to pass into the hands of the 
county councils. The county nursing associations 
have a wide and powerful influence for good, and 
have deserved well of the country. They took up the 
work when it was difficult, and often little appreciated 
even by those who were aided. If the time should 
come, when, as is common in this country, the per- 
manent effort passes from the hands of a voluntary 
agency, into that of the State or of a local authority, 
it is to be hoped that they will receive at least some 
of the thanks and praise which is due to them. 


The Training of Health Visitors. 

So far nothing has been said on the training or qualifica- 
tions which should be possessed by a health visitor. It 
seemed better to give first of all an account of her work 
and then to consider the question of her qualifications. 
The value of the sanitary training was very early 
recognised, as is shown by the very general appoint- 
ment of women sanitary inspectors as health visitors. 
A little later, trained nurses began to take up the 
work as a profession, and undoubtedly in many ways 
they are very suitably trained persons. A nurse's 
training does not, however, include any knowledge of 
either infant or child hygiene, and very few nurses 
have acquired more than a rudimentary knowledge of 
these matters during the course of their training. 
Again, it was realised that a midwife's certificate was 
of great value to those working on child hygiene. No 
definite ruling as to the qualifications of those employed 
by child welfare agencies has been laid down except 
for the Metropolitan area. Regulations were issued 
by the Local Government Board for the qualifications 
of health visitors in the Metropolitan area in 1909. 
These regulations, while not being without their use, 
were so wide that, in effect, they would not necessarily 
have achieved much. They required a health visitor 
to have one or other of the following qualifications : 

(a) a medical degree ; 

(&) a nurse's training ; 


(c) a midwife's certificate ; 

(d) some nursing training and tlie health visitor's 

certificate of a society approved by the 
Board ; 

(e) the previous discharge of duties of a similar 

character in the service of a local 

Fortunately, the good sense of the borough councils, 
acting on the advice of the medical ofl&cers of health, 
backed by the fact that the appointments must be 
approved by the Local Government Board, prevented 
any misuse of the last words, and so far as can be 
ascertained, no one without at least one of the above 
qualifications other than (e) was appointed in the 
Metropolitan area. 

In the provinces there was no rule, although a very 
large proportion of the women appointed as health 
visitors were trained women. 

Some medical officers of health consider that all 
health visitors should have had a full nurse's training. 
Others attach comparatively little importance to this 
and favour a sanitary inspector's training. Others 
regard the possession of Central Midwives Board 
certificate as essential. The course of training required 
for these special certificates in each case covers more 
groimd than is necessary for child welfare work, and 
omits other important aspects. 

The nurse receives a prolonged traimng in the 
technique of surgical and medical nursing for adults, 
but, under the arrangements prevalent in most training 
schools, she will rarely see a normal baby, and it is very 
unlikely that she will be instructed in the hygiene of 
any stage of life, infant or adult, man or woman. She 
will have no knowledge of sanitation in the home, 
since the ventilation, etc., of the hospital wards is 
arranged without her, and usually follows a fairly fixed 
routine ; there is no reason why she should be acquainted 


with any of the difficulties of hygiene in the ordinary 
small home. She may be without any knowledge of 
midwifery, especially normal midwifery, and have had 
no contact with any matter relating to the hygiene of 
pregnancy. It is not to be expected that she should 
have, for these matters do not form any part of the 
essential recognised training as it stands at present, 
and it is the exceptional person who acquires proficiency 
in any branch of work without training. 

On the other hand, the trained nurse has acquired 
habits of order and discipline, and of regularity in her 
work, and these qualitites are of untold value to all 
workers. For school or tuberculosis work the nurse's 
training is of more direct value than for child welfare 
work, although even for this, as has been stated, there 
are many advantages in the training. 

The training of a sanitary inspector covers many mat- 
ters which are acknowledged to be essential for health 
visitors. It also involves other aspects which are clearly 
of httle or no value ; such, for instance, as meat inspec- 
tion, the details of the laying of drains, etc., and again 
it provides no instruction in child hygiene. 

The Central Midwives Board certificate is even more 
speciahsed, and the training does not ordinarily include 
much training in infant hygiene. It should, however, 
be at once stated that this deficiency is met in some of the 
training schools, and the need for it for the practising 
midwife is very generally recognised. 

No training gives so close an acquaintance with the 
difficulties of the working mother as a midwifery 
training when taken in the " district," that is, midwifery 
work carried out in the home. The psychological value 
is great, but the training does not include enough child 
hygiene and other similar matter, nor can this be 
included in the available time.^ If the period of training 

^ The present length of training for a midwife is six months, or 
four months for one who is a trained nurse. 


were extended to enable a sufl&ciently large acquaintance 
to be gained, the length of time would in itself render 
the midwife's training almost prohibitive for the health 
visitor who must learn other matters as well. 

No one of these trainings can therefore be regarded as 
adequate without further special training. Many- 
health visitors are required to hold more than one of 
these certificates in order that they may have been 
trained in several aspects of child welfare work. The 
Medical Officer to the Local Government Board 
recommended^ that health visitors should possess 
two out of the three qualifications : 
Nurse's training ; 
Sanitary Inspector's certificate ; 
Central Mid wives Board certificate. 

Actually a considerable number of health visitors 
hold all these qualifications, but it must be admitted 
that, especially during the war, women have been 
appointed who do not fall within these requirements. 

Moreover, there are certain important matters which 
a health visitor should know which are, as already 
pointed out, not included in the training for any of these 
certificates. Infant hygiene is one of them. It is 
sometimes supposed that there is no special instruction 
needed in infant hygiene, and that general knowledge 
and training will supply all that is necessary. Doubtless 
some points in child hygiene are similar to those for 
adults, but there is a great deal which is not suppUed by 
the instinctive reasoning processes of the average 

Then, again, none of the above trainings supply any 
knowledge of general social conditions, and it has been 
explained in the preceding chapters that this is of great 

Efforts have been made by various bodies in London 
and the provinces to arrange trainings suitable for 

' Mtmorandum on Htalth Vititort, ato., 1016, p. 7. 


health visitors, and although certificates have been 
given fairly widely, the results achieved have, for 
several reasons, been below what might have been 

It is diflBicult to say precisely why the certificates did 
not meet the situation, and, as the Board of Education 
has now issued regulations in agreement with the 
Ministry of Health, there is no object in making further 
inquiry into the cause. 

Of recent years, many women have taken the Central 
Mid wives Board certificate in order to quahfy them as 
health visitors. This has caused considerable difficulty 
in arranging for the training of those who intended to 
practise as midwives, since the number of places for 
midwifery students is necessarily limited by the material 
required to train on. 

A midwifery training is no doubt a valuable asset to 
any one who is working among the poorer classes of the 
community, be it as public health or social worker. 
The material for training must in the first instance be 
available for those who intend to practise midwifery, 
whether independently or attached to hospitals. More- 
over, when due provision has been made for the training 
of midwives, it will clearly be for the midwives to 
undertake the ante-natal and early post-natal care of 
the mother and child. The health visitor will come in 
after the period of the midwife's attendance. (Cf. also 
the Ministry of Health's circular, Appendix IV.) Just 
now, and for some few years to come, the position is 
more difficult. Many of the midwives have neither 
time nor training to undertake the work as it should be 
done. It is a wiser policy, however, to look ahead and 
make provision for better midwifery service, than to 
require all the health visitors to hold a midwife's certi- 

^ It was necessary for these certificates to be recognised by the 
Local Government Board as tailing within the qualifications laid 
down by them for health visitors in the Metropolitan area. Outside 
this area no regulations were in force. 


ficate. Moreover, the mere possession of a midwife's 
certificate does not cany with it more than a rudi- 
mentary knowledge of ante-natal hygiene, and practical 
experience must be added to the midwife's training before 
good ante-natal care can be given. The health visitor 
must follow the midwife or doctor, and carry the child 
up to and through school age, and her training should 
be directed towards this end. 

The Board of Education regulations which have been 
recently issued provide a curriculum of study and prac- 
tical work for the health visitor which seems to cover 
all the requirements, and when in full working order 
should secure an admirable training for those intending 
to take up any form of work for maternity and child 
welfare. The courses of study will be held at insti- 
tutions connected with universities, which must make 
due arrangement for practical work. 

The training includes : 

(1) A general knowledge of elementary physiology, 

so that having some understanding of the 
working of the body, in health, they may 
appreciate the object of the measures adopted 
in preventive work. 

(2) A short course in artisan cookery, so that the 

health visitor may reaUse the limitations 
and difficulties caused by a small income, 
and by the necessity of cooking with only 
a few cookery utenails. 

(3) A full course in general hygiene and in infant 

and child hygiene work of all forms, with 
much practical work at a centre, and also 
instruction and practice in school clinics 
and in tuberculosis work. Also instruction 
in infectious diseases and minor ailments 
of children, together with some acquaintance 
with maternity work. 

(4) Lectures on social work, its methods, objects, 


etc., and some practical work, in order that 
the visitor may have at least some know- 
ledge and realisation of the difficulties, 
and of the facilities which are available to 
deal with them. 
The regulations for training should, if properly carried 
out and enforced, lead to a great improvement in the 
quality of the work of the health visitor, and thence to 
her status and salary. This last has improved latterly, 
and is likely to improve still further as the value of the 
work is more appreciated and the general level of 
training raised. 

Some 3200 health visitors, some whole-time and some 
part-time, are now employed by local authorities 
in England and Wales.^ Many hundreds more will 
be required as the work expands and health visitors 
seem likely to become a permanent part of the staff of 
every large public health department. Anything 
approaching a detailed discussion on the future 
development of health visiting would only be out of 
place in a work such as this. 

In pointing out the defects of the training and the 
needs of the future, a tribute should be paid to the 
excellent work of many health visitors, both in the early 
days when the whole movement was on its trial, and at 
the present time. It is to their efforts and personalities 
that the work owes its present position. 

Reference has just been made to their personalities, 
and no account of the training and qualifications of a 
health visitor would be complete without some remarks 
upon this vital point. Personality counts so much 
in all relations with our fellows, but in no type of work is 
it so important as in any branch of work where home 
visitation is concerned. There is no one type of per- 
sonality required for the work — there is room for all 
types — but if any one quality can be singled out, then 
* A few hundreds of these are employed by voluntary agencies. 


sympathy were surely that one. Good, even excellent 
work, is done by women of widely different temperaments, 
wholly divergent outlooks, sociable or even almost un- 
friendly manners, if the mothers whom they visit feel 
that the visitor is there to sympathise and not condemn, 
to advise and not to lecture. If the visitor remembers 
that we are all ignorant, and that the difference between 
her own knowledge and the mother's is almost imper- 
ceptible compared with the sum of all knowledge, that 
mistakes are often due to ignorance or carelessness, 
to despair or hopelessness ; if she will put herself in the 
mother's place and ask herself what she might have 
done had she been brought up in a similar manner, had 
her opportunities been as limited, her cares and 
anxieties as great, she will not fail to aid the mother and 
to secure the carrying out of her advice. 

The visitor is there to lead and educate and not to 
drive. There are few who will not finally respond, even 
though it be after several attempts and after the per- 
sistent kindly aid and advice have often been many times 

Those who have worked most intimately among the 
poorer classes of the country are among those who are 
most appreciative of the working-class mothers of this 
country. If they have a family, their work may be 
almost incessant, and their patience sorely taxed. What 
they achieve is wonderful, and, provided that they have 
matters explained carefully and in simple language, so 
that they can see the reason why the advice is being given, 
they will often carry out directions of a difficult char- 
acter with astonishing skill. They like having explana- 
tions as to why things should be done, and every health 
visitor should be able to give simple reasons for her advice. 
She must not be impatient if the reasons are not 
remembered on the first occasion. It all appears simple 
to the visitor, but it is new to the mother. Those even 
among the so-called educated classes who remember 


and grasp what they are told on the first occasion are 
comparatively few in number, and may safely be re- 
garded as having more than the ordinary amount of 

It is hard to estimate the extent of the results already 
achieved by health visitors, but it can safely be asserted 
that, as a result of many efforts, the general level of 
knowledge among all classes on the subject of infant 
hygiene has risen enormously during the last decade, 
and a considerable part at least of this result may be 
attributed to the health visitor. 

Movements have cumulative force, and the next decade 
will almost certainly see advances compared with which 
the present progress will appear very small, but it is the 
begirming which is always so difficult. 


The Position of Voluntary Agencies in Child 
Welfare Work ^ 

The child welfare movement illustrates very well a 
characteristic feature of many movements in this country. 
A beginning is made by a body composed of a few phil- 
anthropically disposed persons, who feel that some 
effort must be made to meet an existing need. Although 
the towns commenced the home visitation of infants 
many years ago, yet a great part of the early work was 
due to voluntary agencies, or to the initiative of private 
persons. Home visitation was attempted in a number of 
districts, and, in a very few cases, was continued for a 
good many years. As a whole, however, home visitation 
proved too exacting a work for the majority of untrained 
and unpaid workers, and the visiting was either taken 
over by the local authority, or a salaried worker was 
employed by the society. 

The main sphere of voluntary work has been in the 
centres. A very large number of these were opened by 
voluntary bodies, and in many cases worked for a num- 
ber of years by voluntary effort. In the Metropolitan 
area, some of the early centres are still under voluntary 
control. At first, the medical officer received no salary. 
As the centres increased, both in number and in size, it 
became evident that a salary must be paid to the medical 

* Throughout thin chapter and elHewhere in this book, the term 
*' voluntary " i» used to denote untrained ns woU as unsalaried 
work, unless otherwise specified. 


ofl&cer, and it also became usual for a trained salaried 
worker to be employed to superintend the work of tlie 
centre, where this last was of any size. The cost of the 
centres thus rose gradually and rendered their main- 
tenance very difficult. In 1914, when Exchequer grants 
were first given, a great stimulus was given to voluntary 
agencies by the receipt of 50 per cent, of the expenditure. 
At the same time, however, local authorities also re- 
ceived grants and their work was expanding rapidly. 
The Local Government Board required all centres 
worked by voluntary agencies who received a grant from 
them, to co-operate with the local authority in its work 
for child welfare. 

In addition to the ever-increasing cost, the sub- 
scribers began to realise that the work could be taken 
over by the local authority, at the cost of the rates, 
and the collection of money became more arduous. 

In the provinces, comparatively few of the older 
centres are still worked by voluntary agencies, and 
even where this is the case many of them are receiving 
substantial subsidies from the rates for some, at least, 
of the branches of work. A number of fresh centres 
have sprung up under voluntary auspices, with the 
definite object of proving to the local authority that 
there was a need for a centre in a particular district. 
When this need has been proved,, it was hoped that the 
local authority would be prepared to take over the 
centre, and in some cases a more or less definite under- 
taking to this effect was obtained in the first instance. 
While a great many voluntary bodies undertaking 
child welfare work have ceased to exist, many have 
given up their work most reluctantly, and others are 
struggling hard to maintain themselves. Some, in all 
a not inconsiderable number, have rehnquished one 
form of activity to commence another, generally one 
for which money from the rates was not at that time 
available. In this way it has been possible to enlarge 


the work in many directions and to gain valuable ex- 

At the present time there are few branches of work 
connected with a centre for which the money cannot 
be levied from the rates. Practically, the only phases 
which still require unaided voluntary effort are material 
assistance and medical or surgical treatment in the 
homes ; rate and State aid are available for all branches 
of midwifery and maternity aid, and for certain branches 
of medical and surgical care among children. 

Why then, it may be asked, do voluntary agencies 
struggle to continue their work ? No one answer to the 
question can be given ; the position is not very simple. 
In some cases the local authority wall not take over 
the work until they are convinced that all possible 
voluntary effort is exhausted. The council does not 
see any reason why the rates should be charged when 
the money can be raised from other sources. 

There is a school of thought which regards voluntary 
work with much approval, and considers the work of 
local authorities unsatisfactory on the main ground 
that it is too official, too unsympathetic, and so forth. 
They fear that the salaried workers will not listen as 
patiently as the voluntary worker to the difficulties 
of the mother, that order and method will be carried 
out to the ehmination of all pleasantness and sociability. 

These, and other objections, are freely talked of by 
voluntary workers, who fear that the result will be the 
extinction of the good work they have carried on with 
80 much labour and pain. It may be said at once that 
these fears have proved to be wholly without foundation. 
The municipal centres grow in size and increase in 
number and obtain most satisfactory results ; nor are 
there complaints of any lack of sympathy. 

Without depreciating much excellent voluntary work, 
it must be admitted that, with a fair number of notable 
exceptions, there is less efficiency in voluntary child 


welfare work than in that carriedfout by locarauthori- 
ties. This efficiency is found to be tempered by 
sympathy and kindness and the fear of officialism has 
lost a good deal of its force. On the other hand, corn- 
plaints are made of voluntary work in general. It is 
less regular and rehable than salaried work, except in 
the case of very special persons. The average voluntary 
worker is prepared to rehnquish her work at the call of 
other duties or even pleasures. She is not paid and the 
society she works for has no hold on her. They may 
have her services when it is relatively easy. Again, 
in the summer, when the work is often very heavy, the 
voluntary workers leave in a body for their hoUday, and 
the work falls through or is left in the hands of the 
salaried members of the staff. There are one or two 
voluntary agencies where the workers have consistently 
remained faithful to their work and have arranged their 
hohdays in relays. Honour and thanks are due to them, 
but they are the exception to the rule. 

Voluntary workers not infrequently have ideas of 
their own on methods of work, and, when the funds are 
in their control, they have the power to carry their 
theories into practice. The conditions accompanying 
the giving of grants have had the effect of levelUng up a 
number of centres and of preventing many excrescences. 
It is unfortunate that voluntary workers in control of 
their own society do not always seem prepared to adapt 
their view to the good of the greater number. Hence, 
it is often far from easy for a local authority to work 
side by side with a voluntary agency, and, in general, 
it is found necessary to assume the control of a centre 
which is taken over or heavily subsidised by the 

If the centre is of considerable size, it is possible to 
divide the activities and to leave certain of them in the 
hands of the voluntary workers and under their com- 
mittee of management. Such activities are most 


frequently the various classes whicli are held, the pro- 
vision of teas, or of food, competitions, and so forth. 

In any case efforts should be made to secure the 
services of voluntary workers for this style of work, 
and also for assistance in the less responsible duties 
connected with an infant consultation. 

There is a sphere for the voluntary worker in child 
welfare work, but it is a subordinate sphere, because 
the untrained worker is not fitted for the branches 
of work where training is essential. A few trained 
but unsalaried workers exist, but they are rare, and 
ordinarily the voluntary worker is untrained. Some 
attend a few courses of lectures and acquire a fair 
amount of rather unsystematic information, which 
renders them more intelligent in their work but does not 
raise them to the level of a properly trained worker. 

Generally, the function of voluntary workers is to be 
pioneers to carry out new ideas on a sufficiently satis- 
factory basis to render it evident that the expenditure 
of public money upon those particular lines of work is 

Hard and honourable have been the tasks laid upon 
and carried out by voluntary effort in this country, but 
the work once justified, the primary need for voluntary 
aid has ceased, and the efforts should then be directed 
into other channels. Pioneer work seldom receives the 
meed of recognition and of praise which is its due ; but 
the pioneer who is a student of history will reahse that 
the human race has ever paid more attention to the 
final success rather than to the uphill path laid out by 
the toil and trodden by the weary feet of the originators. 


Other Phases of Child Welfare Work 

In this chapter a few remarks are made on the provision 
and work of day nurseries or creches, on nursery- 
schools, and other " homes " for infants or young 

Day nurseries and nursery schools are non-resident 
institutions, whereas in a " home " the children are 
nearly always resident. Both day nurseries and nursery 
schools are eligible for grants-in-aid. Nursery schoofe 
now fall under the Education Act of 1918, and receive 
their grant from the Board of Education. For a time 
also creches were under the same Board, but, with the 
establishment of the Ministry of Health, they passed 
out of the province of education and came under the 
auspices of the Ministry of Health. 

Both the Board of Education and the Ministry of 
Health issued memoranda dealing with the require- 
ments and general arrangement which are necessary 
in order to obtain State aid. The memoranda cover 
so much of the working of these institutions, that any 
further disquisition on them would, in effect, be merely 
another presentation of the same facts. There are, 
however, certain aspects of the work, especially of 
day nurseries, which do not fall within the province 
of such a memorandum. These points relate to the 
general advisability of the institutions and to the 
precautions which are necessary. A Government 
Department does not ordinarily discourage any form 


of work which may have useful aspects. Its object is 
to cultivate the good points, and to reduce the difl&culties 
which may arise, in order to secure the maximum 
value of the work. 

The main difference between a creche and a nursery 
school lies in the age of the children, and, consequently, 
in the provision made for them. Children are usually 
admitted to creches after the j&rst month or six weeks 
of life, although this is really far too young, and they 
may remain up to the age of three, or sometimes rather 
older. (Cf. paragraph 2 of the memorandum in 
Appendix V.) Nursery schools are for children of 
about two or three years of age until they attend 
school, which is usually at the age of five. Different 
arrangements are required for the two types, and the 
objects also are different. 

Nursery schools provide occupation, and should 
inculcate habits of order. The term " school " is 
lightly interpreted, and the children much enjoy their 
games and little lessons. 

There is more risk of infection from a number of 
children of this age than with those at school, but 
as a whole, the nursery school may be regarded 
as a valuable institution. The regulations issued by 
the Board of Education deal with the psychological 
as well as with the physical side of the work of nursery 
schools. Although it is hardly possible to print the 
regulations as a whole in the text. Appendix V, which 
is a reprint of the regulations, is intended to be regarded 
as belonging to the main text, and should be read with 
it. It has already been mentioned that the child of 
two or three years of age partakes, in regard to its 
physical side, of the nature of the older child. It 
has ceased to be an infant, and both its mental and 
physical needs are distinct from those of the younger 

The day nursery, however, requires very careful 


watching. It is by no means a movement which 
should be allowed to spread to any great extent : it 
does not stand alone, but involves many other very 
important social matters. 

The object of a day nursery is to provide some place 
where a woman who is going out to work may leave 
her child. Some amount of work by married women, 
or widows with children to look after, may be un- 
avoidable, but ordinary outside work should not be 
done by a woman with young children under three. 
There are plenty of women with older children, or no 
children, who can go out to work, and during the years 
when the children are young the mother should stay 
at home. 

At present, no doubt, this is a counsel of perfection, 
and there are many women who are obliged by the 
conditions of their existence to go out to work in order 
to earn money.^ 

It has been proved beyond a doubt that, generally, 
all aggregations of young children involve a risk. 
There are subtle troubles, presumably bacterial in origin, 
which, while not amounting to any definite ailment, 
affect the general well-being of the young child. These 
" infections " appear to arise with the utmost ease 
when young children are close together, and the " in- 
fection " is carried from one to the other. ^ The cause 
is unknown, or there may be many causes, but the 

* During the war crtehes became almost a national need. The 
conditions were quite exceptional, and the work of the mother was 
for the time being of such value to the nation as to justify the risk 
to the child. The provision of creches attached to factories does 
not appear to command great success. 

* This aspect of work among children was studied very closely 
in Germany many years before the war ; it is unfortunate that, 
although the German literature contained abimdant references to 
this difficulty, no nation paid any serious attention to it. America 
is now realising the position, and there are signs of an awakening 
here among some leaders of thought in this coimtry, but insufficient 
appreciation of this danger has often led to trouble. 


general fact remains securely established, repeating 
itself whenever opportunity occurs. The child so 
"infected " just does not progress ; it looks pale, and 
is not putting on sufficient weight ; or there may be 
a rash or some slight skin trouble. The manifesta- 
tions are various, but the net result is that the child's 
condition, while not serious, is unsatisfactory. The 
axiom laid down by the German investigators that 
each infant in an institution where there were other 
infants, should be regarded as a source of potential 
infection for others, is true. It has arisen out of a 
wider experience of less satisfactory arrangements 
than the one postulated, but its recommendations 
have been amply justified when carried out in practice. 
The axiom applies most forcibly to resident institutions, 
but is operative also in one like a creche, where the 
children are close together during the day. It is merely 
a question of the duration of the time of potential 
infection : the child is exposed to risk for a shorter 
period and its return home at night is very beneficial 
to it. On the other hand, the cots in a creche, and the 
quarters generally, are usually much closer together 
and the service provided less well trained than in a 
resident institution for children. 

The general position has been appreciated for many 
years in hospitals. All those who are connected with 
children's hospitals are aware that very young children 
should be sent out of hospital as soon as they are at 
all well enough, and, ordinarily, very young children 
do better in a woman's ward than in a ward by them- 
selves. The cause is the potential infectivity of one 
child for another, and the " infection " can be trans- 
mitted direct or carried by the attendants. 

A cr^he, to be satisfactory, must be run on what 
may appear to be unnecessarily expensive lines, as 
will be explained shortly. Moreover, there is the 
further possibility of the introduction of one of the 


ordinary infectious diseases, if such a disease arises 
in the home of one of the infants. 

If every efEort is to be made to avoid the communica- 
tion of infectious disease from one child to others, 
then every child must be carefully examined by a 
skilled worker each day when it arrives. Any case of 
suspicious rash, or running of eyes and nose, should 
be placed in an isolation room until seen by the doctor 
of the creche, who will determine what shall be done. 

In order to avoid the other less known and intangible 
" infections," scrupulous care and cleanhness is 
necessary, and the younger the child, the greater the 
care required. The attendant should wash her hands 
after performing any office for an infant before handhng 
another. Aprons and dresses must be clean, and not 
be sources of infection from the last child taken on to 
the apron. Bottles, etc., must be kept separate for 
each child. The same cots must be kept for the same 
child, or cleaned if used for another one. The bath 
must be washed with disinfectant between use by 
each child. Changes in the child's clothing must be 
made in the cot and not on a pillow used in common 
for all the infants. In fact, the precautions necessary 
are elaborate, and hardly ever fully carried out. 

The children habitually in a creche very rarely are 
as healthy as the children outside : the white, rather 
pinched face and pinkish eyelids are due not only to 
the absence of sufficient fresh air, but also to the 
general result of the aggregation of children without 
the necessary precautions. 

In a few institutions an excellent technique of 
management is observed, and here the troubles above 
referred to do not loom large, more especially if the 
children are kept out of doors. 

Creches without a garden or possible source of fresh 
outdoor air should not be allowed. 

In the present conditions of care in cr^hes the 


infant is probably very much safer with a relatively 
satisfactory " minder " than in a creche. 

If creches are to be well run, the cost is high, and 
cannot be met by the daily charge to the mother. 
Unless, however, the necessary cost can be met, the 
creche should not be in existence, from the hygienic 
point of view. 

In addition to the above considerations, the pro- 
vision of creches may have the effect of inducing 
women to go out to work who could afford to stay at 
home and look after their child. They can supplement 
their husband's income owing to the creche. It would 
be far better for them to stay at home. If their husband's 
wage is inadequate for existence, it is this which should 
receive attention, and the true response is not the 
provision of a creche. There is a good deal of difference 
of opinion as to whether women wish to go out to work 
or not. Doubtless, some prefer being at work, and 
others would prefer to stay at home : there can, how- 
ever, be no doubt that by no known means can the 
mother's care be replaced. The infant should be cared 
for by its own mother wherever this is humanly possible. 
The exceptions there may be will only prove the general 
rule. All mothers who go out to work do not wish 
to make use of a cr^he, even if one were available. 
The cr^he may cost rather less than the charge made 
by the woman who " minds " the baby while the 
mother is at work ; but the creche demands regular 
hours for bringing the child and for removing it, and 
a complaint is made if the child is not brought clean 
in the morning. Again, it may be that the cr^he 
hours for reception do not coincide with the work 
hours of the mother, which may cause an insuperable 
difficulty. Although there is demand for crdche 
accommodation, day nurseries can hardly be regarded 
as supplying a wide need, or as being desirable on a 
large scale. 


The regulations of the Ministry of Health for day 
nurseries, given in Appendix V, should be read in 
conjunction with this chapter. 

Notes on Institutions for Children and " hoarding- 
outy — Institutions variously termed hotels, hostels, 
and homes are now being started, which will take in 
children temporarily in the event of the mother being 
obUged to be away from her home from some cause 
or other. There is much to be said for this provision, 
but the remarks as to the care of the very young children 
apply with full force in such cases. Unless these homes 
or hotels are worked on lines of the most scrupulous 
care, they will not afford the advantage for which 
they have been designed, namely, the welfare of the 
children concerned. 

In general, infants and young children who are 
unable to be kept at home during the day, or who 
have no home, are better boarded out in the homes of 
others. This applies just as, if not more, forcibly to 
infants under one year as to those rather older. Even 
a rather unsatisfactory home is better than a good 
institution, not only from the point of view of health, 
but morally and psychologically. 

The figures available from countries like Sweden 
and Germany, where the boarding-out system is carried 
on widely as the result of experience, leave no doubts 
upon this subject. Due precautions should, of course, 
be taken in regard to the homes where the children 
are boarded, especially if public money is concerned, 
and these should be inspected by some responsible 
person before the child is sent, as well as afterwards. 
The previous inspection of the proposed home is of 
fundamental importance. 

It is not proposed to deal here with the whole question 
of " boarded-out " children. Many Poor Law children 
are boarded out, and there is supervision of the children 
who are taken as boarders for gain under the Children 


Act of 1908 after the child has been taken as a boarder. 
The administration of this has now been transferred 
from the Home Office to the Ministry of Health. All 
such children should fall under the scheme for child 
welfare of the district. Definite requirements should be 
made as to the accommodation provided in the horn ^ and 
the child should be visited by the child welfare visitor. 
Further, when a child welfare centre is reasonably near, 
systematic attendance at the centre for medical advice 
should be laid down as a condition for permission to 
retain the child. 

The boarding-out system should be developed and 
improved, when it will be foxmd to be a very effective 
branch of child welfare. 

In each district there should be a list of suitable women, 
either with small families or without family, who are 
prepared to accept children of specified ages as boarders 
for short or long periods. Such premises should be in- 
spected, and notes should be made of the accommodation, 
etc. It is true that such a system would involve a con- 
siderable amount of work in the first instance, but it is 
work which is well worth doing, and would certainly be 
found to be very repaying. 

It is often stated that any such wide system of board- 
ing-out is impossible in tins country ; that it may be 
possible elsewhere, but could not be done here : that, in 
the first place, it would be impossible to find enough 
accommodation, especially at the figure usually offered for 
boarded-out children. This last — the cost — is in reality 
the key to the whole position. For reasons which are 
obscure to the ordinary individual, a fee of 5s. per week 
was considered an adequate boarding-out fee before the 
war, whereas the exponents of the doctrine of impos- 
sibility were prepared readily to admit that the cost in 
the alternative method — namely, an institution — would 
be at least three to four times as heavy. 

It ia difficult to see why the fee for boarding-out 


should be kept so low as compared with that of an 
institution. It is far better for a child to be kept in a 
good home as a boarder than in any institution, however 
satisfactorily organised. The charge would certainly 
be less than the cost of the institution, and the results 
infinitely more satisfactory. The argument that it would 
would not be possible to obtain a sufficient number of 
private homes for the purpose is merely theoretical, 
since no real effort has ever been made when a fee has 
been offered which is sufficient to cover the cost of main- 
taining the child in a good home without expense being 
incurred by the family. A low fee must mean either 
that the family has a low standard of life, or that it is 
prepared to incur expense in order to have the child. 

The absence of any legal power of adoption might 
prove a more serious matter, since the family might not 
want to risk the subsequent removal of the child they 
had become attached to. But, in the absence of any 
reasonable effort on the general question, it is impossible 
to say how far the difficulty might or might not be real. 

The Ministry of Pensions have recently laid down 
regulations for the boarding-out of children of officers 
or men in the naval, military, and air forces, who, for 
some reason or another, are in need of proper care. 
These regulations recognise the need for careful investi- 
gation of the homes before the child is sent there, and in 
general provide the precautions which are essential for 
boarded-out children. Provision is made for expenditure 
in regard to board, clothing, dental care, etc. The 
working out and development of the scheme will provide 
information and experience of great value. 

Institution life is undoubtedly necessary for many of 
those who, owing to a physical or mental defect, are not 
able to take their place in the daily life of the world. 
For normal children it should be discouraged on every 
count, either temporarily or as a permanent measure. 
There are no two opinions upon the subject among those 


who have had personal experience of a proper system 
of boarding-out under proper supervision, and with 
adequate payment. The promised — presumably im- 
minent — abolition of the Poor Law, together with the 
taking over by the Ministry of Health of the children 
boarded out under the Children Act, and the scheme of 
the Ministry of Pensions, presents a unique opportunity 
of developing an adequate system of boarding-out. 
It would, if successful — and there is every reason why 
it should be so — produce better results at a reduced 
charge to all concerned. 


The Control of the Practice op Midwifery 

It is recognised by all nations that assistance is required 
for all women at childbirth. The arrival of a new indi- 
vidual into the world has held, and will probably continue 
to hold the imagination so long as the world lasts. 
Legends and superstitions in wild confusion have grown 
up around the fact of a birth, and are by no means 
confined to so-called uncivilised tribes or nations. Rites 
and ceremonies are as prevalent as the superstitions, 
and are, most of them, unhygienic and, in general, 
undesirable in the light of modern knowledge. 

The advent of a life into the world is sometimes accom- 
panied by death, either that of the child or of its mother. 
Doubtless, as with other phases of life, certain deaths 
are not preventable in the present state of our knowledge 
and care. It is, however, quite certain that the number 
of children who are born dead could be immensely 
reduced by proper measures, and that the same applies 
to deaths among mothers. 

No problem can be handled without experiment, and 
as experience is gained, the requisite knowledge for 
dealing with difficulties is acquired. How far the 
difficulties — or even the need for investigations of death 
connected with childbirth — were generally realised before 
the latter part of the nineteenth century is hard to say. 
Doubtless the matter was in the minds of some people, 
because no movements commence abruptly ; but no 
widespread movement took place in this country in con- 


nection with improved conditions for childbirth until 
that period. 

There are a number of ancient charities founded for the 
benefit of women in childbirth. They were, however, 
primarily intended to provide either an asylum for the 
confinement <'f the homeless mother, i.e. a hospital, or 
the service of some person for those unable to pay for 
such service themselves — i.e. a maternity charity. 
The intention does not appear to have been the improve- 
ment of existing conditions, but to provide the class of 
aid then available for the poorest mothers of that 

During the last fifty years or less, our knowledge has 
advanced rapidly, and, at the present time, although 
there is yet much to be learnt, we do at least possess 
sufficient knowledge to effect great improvement if the 
necessary effort is forthcoming. 

In no nation do the members of the medical profession 
appear to be the only persons to be called in to assist 
at a birth. The majority of births have always been 
handled by other women. Certain women became 
known as being willing to attend their fellows, and some 
of them gained very considerable experience in the course 
of their work. In this country, until 1902, no re- 
strictions were laid down as to the qualifications of any 
woman assisting at a birth, and any woman might 
assist another one, although in practice the assistance 
was probably rendered by a comparatively small number 
of women. A widow, or some one with few or no home 
ties, would clearly be a suitable person, as she could 
leave home at a moment's notice more readily than 

The Midwives Act of 1902, the first step taken by 
Parliament to improve the conditions then obtaining, 
was the result of a long struggle to introduce improved 
conditions, the importance of which were already known. 
During the nineteenth century great strides had been 


made in the knowledge of treatment and cause of the 
occurrence of abnormal conditions associated with preg- 
nancy and childbirth. Greatly improved conditions had 
become available in most, if not all, the hospitals which 
undertook maternity cases, but the general level of work 
outside was inevitably low, since any one, however 
ignorant, might attend and take charge of a case of 

It is true that childbirth should be regarded as a nor- 
mal process, and this fact should be borne prominently 
in mind. But so are the ordinary functions of the 
body for daily life, eating, drinking, sleeping, etc., and 
yet it is obvious to any one who will bestow a little 
thought upon the subject, that a high proportion 
of the population of most countries do not know, or, if 
they do know, do not practise those principles which 
should be adhered to in order to maintain the processes 
of the body at a normal level. If, therefore, experience 
alone has not taught how to deal with con- 
tinuous occurrence, how much less is it likely to have 
taught the handling of so relatively infrequent a process 
as that of childbirth. 

It must not be supposed that no efforts to secure 
training for those who wished to practise midwifery 
had been made before 1902. Many hospitals held 
courses of training, and gave certificates of proficiency, 
and the Obstetrical Society of London held examinations 
admitting to a Licentiate in Midwifery, and which gave 
the right to a title.^ It is evident, however, that a 
course of training will not be taken voluntarily by the 
average woman who may be prepared to attend a 
neighbour as a midwife, unless she is compelled to do so 
by law. Hospitals, and other institutions dealing with 
maternity cases, employed many trained midwives, and 
it is somewhat surprising how many women had re- 
ceived training, seeing that there was, in effect, no 

^ The title was Licentiate of the Obstetrical Society (L.O.8.). 


compulsion, and only the more enlightened realised 
their need for it. 

The Midwives Act of 1902 required all women wishing 
to practise midwifery to have received a training, or 
to produce evidence of having been known to be in 
honafde practice as a midwife before 1902. These last 
were untrained, and are frequently distinguished from 
the former by the term bona fide. A few bona 
fide midwives may have received some training, but 
they hold no certificates to that effect. Both classes 
of women were to have their names inscribed on the 
Midwives EoU, which was first made in 1905. The 
Roll is revised annually under the auspices of the 
Central Midwives Board. 

In addition to this fundamental provision for con- 
trolling the practice of midwifery, the Act provided for 
the establishment of a central controlling body, the 
Central Midwives Board, which was placed as in the 
previous case of the medical and dental professions, 
under the control of the Privy Council.^ 

This body received power to make rules to be observed 
by all midwives on the roll, to hold examinations, grant 
certificates of proficiency, and to remove from the roll 
the name of any midwife found not to obey the rules, 
or to be guilty of unprofessional conduct. 

Further, the Act provided that the supervision of 
midwives should be in the hands of county councils and 
county borough councils. All women desirous of 
practising as midwives were required to send in their 
names and addresses, together with evidence of trainmg, 
or of bona fide practice before 1902, to the medical 
officer of health of the council, who, after due investi- 
gation, was to forward the completed list to the Central 
Midwives Board. The notification of intention to 

» Undor the Ministrv of Health Act of 1919 the Contral Midwives 
Board hoB been transferred from the Privy Onunoil to the Ministry 
of Health. 


practise must be made each year, and a fresh list furnished 
to the Central Midwives Board. 

The councils concerned were required to appoint an 
inspector of midwives to supervise the work of the mid- 
wives in their area, and to report cases of irregularity 
or of breach of rules to the Central Midwives Boards 
Penalties were also provided for, against those who, 
not being on the Midwives Roll, practised midwifery 
for gain, unless in an emergency. 

The Act was originally designed to come into opera- 
tion in 1905, but for reasons which need not be gone 
into, it did not become operative until 1910. 

The movement for the improvement of midwifery 
care obtained legal powers before that for child welfare, 
since the Notification of Births Act was passed in 1907. 
While the Midwives RoU, and the functions of the 
Central Midwives Board, would, no doubt, have pro- 
duced a great effect on midwifery work, it is certain 
that a rapid impetus has been given to midwifery 
through the child welfare movement. This impetus, 
however, could not have been given without the Mid- 
wives Act of 1902, and the machinery which had been 
set up under it. 

The rules of the Central Midwives Board, which must 
be observed by all midwives, were first issued in 1911, 
and were re-issued, with certain alterations, in 1916. 

In these rules certain definite instructions were 
laid down for the practice of midwives, dealing with 
the provision of adequate appUances, cleanliness of 

^ The Act of 1902 allowed County Councils to delegate the in- 
spection to the smaller Local Authorities, and, in the first instance, 
many took advantage of the permission. As, however, the import- 
ance of the work became recognised, the delegation was rescinded 
by practically all the counties. Some of the larger borough and 
urban districts, however, clamoured for the powers of inspection 
to be placed in their hands as a part of their scheme for Child 
Welfai-e. The subject aroused much controversy, but was finally 
settled against delegation by the Midwives Act of 1918, which 
rescinded the original clause in the Act of 1902. 



person, of the care of the patient, the occasions on 
which surgical aid should be advised, the keeping of a 
register of cases attended, and a record of each case — 
piilse, temperature, and general conditions, etc. — 
during the period of the midwife's attendance. The 
midwife was required to attend the mother when 
summoned, and to be responsible for the care of both 
mother and child for ten days after birth. If- a doctor 
was called in, the midwife worked under him or her, 
and, if the mother had not recovered by the tenth 
day, or the child was still requiring attention, the 
midwife was to continue to attend after the tenth day. 
Great difficulty arose in the case of many of the 
untrained midwives who formed the majority of those 
on the first roll. The first Report of the Central 
Midwuves Board, 1905, stated that, as far as could 
be ascertained, there were 22,308 women who were 
entitled to be registered. Of these, 12,521 were in 
bona fide practice before 1902, and 9787 held certificates 
in midwifery, making a total of 22,308. These figures 
cannot, however, be regarded as absolute, since in the 
early years many midwives in practice doubtless did 
not notify their intention, and there was no machinery 
for getting to know of their whereabouts. On the 
other hand, of those registered, a considerable number 
were imdertaking little or no practice, and others were 
attached to hospitals or other institutions. The 
number of names on the Midwives Roll does not, even 
now, furnish more than an approximately accurate 
figure of the number of midwives in practice inde- 
pendently, as apart from those who are trained. The 
percentages of trained and untrained, as shown by the 
figures given above, are 43 and 56, that is to say, con- 
siderably over one -half of all the midwives in practice 
were untrained, and since there were probably a fair 
number not included, and as many of the trained 
midwives were not in practice, the figures for untrained 


midwives in practice were almost certainly much higher. 
In fact, the bulk of the practice of midwifery by mid- 
wives was in the hands of untrained women. Of 
these a fair number were unable to either read or write, 
and were wholly ignorant of even the rudimentary 
principles of modern practice. It was impossible for 
them to obey the rules, as they did not know what 
they involved, and some of them could not keep records, 
as they could not read the thermometer and write 
the records. It might be thought that such women 
should not have been allowed to register. This would 
have led to difficulty. In the first place, the nation 
has a rooted objection to the summary abolition of 
any vested interest, however injurious such an interest 
may be to the community at large. Secondly, in many 
districts, especially in the rural areas, there was no one 
else, and the refusal to register such a woman would 
simply have meant that she or other unregistered 
women would practise, since the work had to be done 
by some one. It was better to register them, and hope 
to improve matters as time went on. 

The first need was evidently instruction, which 
could be carried out in connection with the inspection 
of midwives. The councils, almost universally, ap- 
pointed their medical officers of health inspectors of 
midwives. But this officer could evidently not spare 
time to undertake anything approaching either a 
systematic inspection or instruction of the midwives. 
Arrangements for these are of the highest importance 
in connection with the improvement in midwifery, 
and while some districts have carried out both branches 
with zeal and efficiency, it is regrettable that even now 
many are sadly deficient in this branch of their work. 

The councils responsible for the inspection of mid- 
wives are known as the Local Supervising Authority, 
and the rules of the Central Midwives Board require 
the midwife to notify to the local supervising authority 


all cases where she has advised medical aid, all cases 
of puerperal fever and of inflammation of the eyes 
(ophthalmia neonatorum). In 1915, the duty was 
laid on the midwife of either notifying these last cases 
herself to the local sanitary authority, or of satisfying 
herself that the doctor called in would notify. In 
county boroughs, the local supervising authority 
and the local sanitary authority are the same, but 
not in the counties. Special books are arranged for 
all these purposes. Some authorities have provided 
them for the midwives in their district free of charge, 
and others have made a charge for them. Under the 
Midwives Act of 1918 the local supervising authority 
is required to provide the books, and to pay postage 
where such is necessary. The inspector of midwives 
should visit the midwives after any of the above notifica- 
tions has been received, and, if necessary, the case 
as well, in order to ascertain how far any fault in practice 
may have occurred, and to prevent its recurrence. 

It is impossible for the medical officer of health 
to undertake the work himself. Some one else must 
be appointed. Some of the county nursing associa- 
tions which were well-estabUshed, had their super- 
intendent, who inspected the work of their affiliated 
associations. The associations employed trained 
women almost exclusively, so that the untrained, and 
others working independently, were not reached in 
this way. Some counties appointed the superintendent 
as their inspector, others provided a special officer, 
while others again employed the health visitor as 
inspector of midwives. The work is difficult and 
costly, but immensely repa^ng and important. The 
appointment of the supermtendent of the county 
nursing association has advantages, as has already 
been mentioned (see pp. 97, 9S), but it often meant 
that the medical officer of health left the work to her, 
and that difficulties arose over the dual control, although 


in some cases it worked well. Some local super- 
vising authorities appointed these special officers, who 
did, and still do, excellent work. They are mostly- 
employed by county councils. They are almost 
always trained nurses with midwifery experience, and 
often other additional quaUfications. Very rarely, 
however, has a county appointed a large enough staff 
to carry on the work adequately. One woman has 
perhaps been provided to work the whole county with 
the aid of the train and a bicycle. It need hardly be 
stated that it was found impossible to carry out the 
work at all efficiently. Midwives should be visited 
without previous appointment not less than three or 
four times in a year, and also after the receipt of notices 
of advising medical aid, of the supervention of puerperal 
fever, or of ophthalmia neonatorum. 

In order to relieve the county medical officer of the 
inspection of midwives, some authorities have placed the 
duty upon the health visitors. In theory this is very 
economical and satisfactory, but in practice it is not to 
be recommended. In the counties there is something 
to be said for it, if all the health visitors were trained 
midwives, and had all had a good deal of experience of 
midwifery. But this last asset can hardly be expected 
and, in fact, is rare among health visitors. It could not 
reasonably be expected. Hence, it often happens that 
the midwives are inspected by some one of less experience 
than themselves. In counties where travelling is diffi- 
cult, it has been arranged that the health visitor should do 
some of the routine inspection, leaving the more difficult 
work for a more fully equipped inspector of midwives. 
In the county boroughs the suggestion has never had 
anj^hing to recommend it, except the plea of economy 
for the ratepayers. Apart from the lack of experience, 
the health visitor will have too few midwives in her 
district to be really in touch with midwifery work. If 
one person does the work for the whole town, she is 


constantly dealing with the cases and the midwives, and 
better work is done. A competent inspector deserves a 
good salary, and so it is considered less expensive to put 
the duty on the health visitor as a part of her routine work. 

The inspection of midwives requires many qualities 
and much experience in the inspector. The routine 
examination of the midwife's bag, etc., is an insignificant 
part of the work. The inspector must be prepared to 
give advice and help on all matters connected with the 
midwife's work. She must instruct the ignorant, and 
endeavour to keep all the midwives up-to-date in their 
work and methods. 

In a few counties and county boroughs excellent 
work has been carried out, and the whole level of 
midwifery work raised. It is astonishmg what good 
results can be achieved by a really good inspector. 
With the object lessons before them it is remarkable 
that many authorities hav3 remained very backward 
in providing suitable persons for the work. The mid- 
wives in many districts have not been given a real 
chance of improving. The Midwives Act undoubtedly 
intended that the inspectors should produce a general 
raising of the standard of work. Unless an inspector is 
appointed who is capable of doing this, and who is not 
given 80 much to do that it cannot be well done, the 
Act loses its value. The Circular of the Ministry of 
Health of July 1919^ deals with the question, and 
urges local supervising authorities to appoint medical 
women as inspectors of midwives, or, if it is unavoidable 
that a non-medical woman be employed, " it is essential 
that she should not only possess the certificate of the 
Central Midwives -Board, but should have had sub- 
stantial practice as a midwife." 

The elimination of the unregistered woman practising 
as a midwife has been greatly aided by the notification 
of births. When the notification is signed by some one 

* Circular 4, given in Appendix IV. 


not known as a doctor or midwife, inquiry can be made 
as to who attended the birth. In this way a number of 
women who were continuing to practise without being 
eligible for registration have been discovered. A woman 
who is on the roll can be controlled by inspection, but a 
woman who is not registered is difficult to trace without 
either the notification or a wide knowledge of the district, 
which last comes only by continuous work therein for 
some years. 

A midwife who breaks her rules is usually warned by 
the inspector, and if the breach is persisted in the woman 
can be summoned before the Central Midwives Board, 
who may caution her or remove her name from the roll. 
At the present time there is a very serious difficulty in 
dealing with some of these cases. The shortage of prac- 
tising midwives is so great, owing to unsatisfactory 
conditions and remuneration of the majority of midwives, 
that if, in a rural district, an independent midwife is 
taken off the roll, she may, of necessity, go on practising, 
although under the Midwives Act of 1918 she may be 
prohibited from giving any form of maternity aid other 
than in an emergency. This difficulty will not be 
remedied until considerable sums of public money are 
spent upon midwifery work. 

The untrained midwife will soon become a thing of the 
past, since no more are admitted to the roll. Under 
continued instruction some of them learn to do their 
work much better, but, in certain matters, the absence 
of adequate training can never be remedied. They have, 
for the most part, not received much education, and 
many are elderly. 

The duties laid upon the midwives are becoming 
more exacting, and demand more knowledge. The 
training now extends over six months, and it is not un- 
likely that a further exterision may be required. It is 
not possible for a midwife to learn all she should know in 
six months, and when she has completed that, or even 


a longer course, she will still need experience before she 
becomes a reliable midwife. 

A few words are needed upon the subject of midwifery 
work by doctors. All medical men and women must 
take a qualifying course in midwifery. After passing 
the final medical examinations no further experience is 
required. It is now very widely admitted that the 
training in midwifery in most medical schools is un- 
satisfactory and inadequate ; that a much higher 
standard of work is required, and that facilities must be 
offered for post graduate work.^ 

There is no control over the practice of midwifery by 
the medical profession, and it is, therefore, all the more 
important that the work should be of such a character as 
to render any question of control unnecessary. 

^ Of. Report on Teaching of Obstetrics, etc., Proc. Roy. Soc. Med., 
23rd June 1919. 


Pre-natal Work 

Midwifery aid may be rendered by either a doctor or a 
midwife. Although the duties assigned to each are 
similar in some phases, generally there is a great diver- 
gence of function. In order to bring out points both of 
similarity and of divergence, it will be convenient to 
regard the whole episode of childbirth as falling into 
three periods, the pre-natal, natal, and post-natal. 
The first of these is considered in this chapter. 

The Pre-natal Period. — This period includes the 
whole duration of pregnancy, namely, about 40 weeks. 
Until recently, very little attention has been bestowed 
upon this period, and such attention was regarded as 
almost unnecessary by the professions concerned, and as 
indelicate by those outside. As a matter of fact there 
is no doubt that this is a most important period, both 
for the health of the mother and of the child. The 
teaching of all the experience with child welfare work 
has been to throw back further the need for care from 
the period after birth to the period before birth, and then 
yet further back to the health of the mother before 

Nature has made remarkable provision for the child 
before birth, and, although our knowledge is still very 
rudimentary upon many important points, there is no 
doubt that the child is safeguarded, and many healthy 
children are borne by rather unhealthy women. But 
there is always the risk. We do not know how far a 


mother may have poor health without affecting the 
child, and there can be no manner of doubt that it is our 
duty to secure the best possible state of health for the 
prospective mother. The appalling mass of minor 
ailments, borne almost without comment by the work- 
ing-class women of this country (and probably of all 
countries), is realised by those who work in some of the 
more up-to-date maternity departments of our large 

It is sometimes assumed that the only treatment 
required during pregnancy is that relating to some 
trouble directly connected with the organs concerned. 
It is argued by some that if the general ailments of all 
pregnant women are to be treated it will involve a tre- 
mendous amount of work. This argument, in effect, 
only illustrates forcefully the prevalence of ill-health 
due to general conditions among the mass of women of 
this country. The woman who is anaemic, or suffers 
from indigestion, or has a number of bad teeth, or has a 
tendency to chronic bronchitis, or to varicose veins, 
etc., will probably find her suffering from these causes 
accentuated during pregnancy. After the confinement 
her recovery will probably be slower than that of her 
healthier fellow- woman. Again, how often are con- 
ditions which may cause trouble detected too late. 
Many causes of cardiac disease are not troublesome 
to the individual concerned so long as she pursues a 
fairly even daily life. But under the strain of the con- 
finement a breakdown may occur, which, if no previous 
examination has been made, is quite imaccountable, and 
possibly very alarming. If, however, such an exam- 

^ The amount of pre-natal sickness was hopelessly underestimated 
in connection with the Insurance Act, which has been one of the 
means of bringing to light the condition of ill-health of many 
working-clasB motners. So great has been the award of pre-natal 
Bickncfls benefit that the financial difficulticH in which the Insurance 
Societies found themselves tor this itomot expenditure have caused 
much embarrassment, both to them and to the Qovemment. 


ination has been made, and the trouble is known, proper 
measures can be taken, and the danger reduced, if not 
almost eliminated. Many other important instances 
could be cited. 

Another point of vital importance is the search for, and 
removal of, all septic foci. It is believed that many- 
cases of puerperal fever arise from autogenic infection, 
through one or other form of septic trouble which could 
and should have been dealt with in the pre-natal period. 
Of recent years several cases of death from fever in the 
puerperium have been found to be due solely to the septic 
condition of the woman's teeth and mouth generally. 
No one system of the body works independently of the 
others. No ailment should be neglected in the pregnant 
woman, whether it be due directly to pregnancy or not. 
A medical examination will, doubtless, soon be regarded 
as a necessary measure on preventive grounds alone, just 
to be sure that all is in order, but, at present, the idea 
is new, and will take a little time to mature. 

But medical care in the pre-natal period is not the only 
care required. The mother wants advice for her daily 
life, for the provision of clothing for the infant, the 
arrangements which should be made for the confine- 
ment itself, instruction as to the importance of breast- 
feeding and its technique, and many other matters. At 
no time is the mother more open to instruction than 
during this long period of waiting, and it is then she needs 
help with a view to securing the best conditions for 
the child. The last items can fitly be carried out by a 
trained midwife if she herself received training on these 
lines. The revised rules of the Central Midwives 
Board of 1916 require the midwife to do ante-natal 
work for her cases. Some midwives have already 
practised this, but the majority have not as yet done 
so on various grounds. 

It is usual to engage the doctor or midwife some 
months before the con&iement is expected. The object 


would appear to have been to ensure that, in the event of 
a premature birth, the relations might know whom to 
send for, rather than that any care was expected during 
this period.^ At present, although matters are improv- 
ing, not much ante-natal work is done as compared with 
that which is left undone. Where a doctor is engaged, 
the provisions for the conj&nement, etc., will probably 
not be gone into, nor does it appear reasonable to 
expect it in view of the fee charged. This is a strong 
argument for requiring that there should be a midwife 
for all cases, even when there is also a doctor engaged. 
The ante-natal period is the time to deal with these 
matters. When a midwife is engaged to attend the case, 
she must, under her rules, satisfy herself that the patient 
is in good health, and, if not, advise her to seek 
medical aid. This, however, many women are re- 
luctant to do, both because it usually involves the pay- 
ment of the doctor's fee, and because they are unwilling 
to submit themselves to examination. 

The ante-natal clinics at the child welfare centres 
should obviate the difficulty of fees, but many mid- 
wives are unwilling to send their patients to them. It 
is useless to deny that there has been a good deal of ill- 
feeling on this point, and that a good deal of it is quite 
comprehensible. There is a most astonishing ignorance 
on the part of many doctors and nurses as to the position 
of the midwife's practice. The hospital training schools 
for doctors and nurses as a whole neither know nor, is 
it to be feared, care about the midwives who are in prac- 
tice in the district, and the ignorance results in lack of 
sympathy when brought into contact with them. The 
midwife is dependent upon her cases for her livelihood, 
and cannot afford to lose them. The complaint has been 

i Abo in tho days before the Insurance Act and the consequent 
Maternity Benefit, it was very usual for the midwife's fee to be 
paid in small instalments betore the ounfinement. This practice 
carried w'th it the necessity for booking early with the midwife. 


made, with apparently a good deal of cause, that when 
midwives refer their cases to the centre, the patient may 
be told that she ought to engage a doctor, or go to a 
hospital, or she may be alarmed, but in each instance the 
loss falls upon the midwife. If the patient seeks a 
doctor, she leaves the midwife, and if she is alarmed 
she does the same, lest the midwife should try to per- 
suade her to attend again. Hence she frequently goes 
to another and less conscientious midwife. 

If any real widespread good is to arise out of the ante- 
natal work at the centres, the midwives must receive due 
consideration. They are licensed by the State to practise 
midwifery, and it is their livelihood. It behoves the 
centres therefore to treat them with respect before their 
patients, whether the midwife is actually present or not, 
remembering that professional etiquette should be ob- 
served towards them. 

Midwives should be encouraged to attend with their 
patients, but too often, unless an effort is made not 
to keep the midwife waiting, she will have neither 
time nor incUnation to do so. 

Some midwives have special days or hours when 
they are at home, and their patients can come and 
see them. On this occasion they can do much in the 
way of instruction. At least one visit, however, should 
be paid to the home to see its degree of cleanliness, 
and the state of other conditions for the confinement. 
This visit should be paid fairly early, since other visits 
may be required to obtain the arrangements which 
are necessary. The midwife has unexampled oppor- 
tunities — she influences the mother in a way that 
others do not. She comes in at a malleable period in 
the mother's Ufe, and she assists at its most intimate 
duties. But she must have time to do this, and time 
costs money, and she must also have training. As 
the mother would probably be neither able nor willing 
to pay for the midwife's time for ante-natal care (since 


she does not realise its importance) this must almost 
certainly be provided out of public funds. 

The Handywoman or " Home Help." — One other 
matter requires attention before the birth of the child, 
namely, the care of the home while the mother herself 
is laid aside. It is usual to engage a neighbour to 
come in and attend to the husband and children (if 
any) and to see after the home generally. This woman 
is often termed the handywoman. A full account of 
the handywoman is perhaps hardly in place in connec- 
tion with ante-natal work. But she is an ever-present 
difl&culty, and can be hardly introduced too early into 
the midwifery picture. 

When a midwife is engaged, this woman should not 
be allowed to do the nursing of the mother : she should 
confine herself entirely to domestic matters and leave 
the nursing to the midwife, and the midwife should 
see that she does so. Unfortunately, many of the 
women consider their knowledge adequate to interfere. 
They are usually sent for with the first indication of 
the onset of labour, and are not infrequently so mis- 
guided as to delay sending for the midwife until too 
late, so that the latter arrives without proper time 
to make preparation, or even, sometimes, after the 
birth of the child. Midwives who know that they 
have to report any untoward occurrence to their in- 
spectors, generally make a stand on the necessity of 
being sent for in time, but it is none the less a difficulty. 

The handywoman is, however, more actively danger- 
ous when a doctor is engaged. The doctor may be 
on his rounds when sent for, and for one reason or 
another, may be unable to attend in time. In such 
cases the handywoman conducts the case herself, and 
is, unfortunately, often proud of doing so. In fact, it 
is well known that some of them do not send for the 
doctor unless they think that there is something 
wrong, and it is to be feared that they do not always 


receive that reprimand from the doctor to which they 
are certainly richly entitled. Such a deHvery is, in 
efiect, illegal, but the woman would plead that the 
doctor had not arrived, and that she acted for the 
best. It is very difficult to prove the contrary, although 
it is well known that some of these women boast of 
being able to manage quite well without the doctor. 

A remedy for this is urgent. The women are ignorant 
of all the proper care at a confinement ; have no 
apparatus, are often dirty in their person and in their 
methods, and the risks run by the patient are very 

The only way to get over the difficulty is to arrange 
that a midwife shall be engaged as well as a doctor, 
80 that, if the doctor fails, proper assistance is at hand. 
Further, in such a case, the doctor need not be sent 
for unless some compUcation should supervene. 

The handywoman usually places a high value on 
her services, and makes a relatively heavy charge to 
the mother. These charges vary a good deal from 
district to district, and in accordance with the work 
done, i.e. the number of children, whether the family 
washing has to be done, whether food is provided or 
not, and so forth. Probably the least sum which her 
services cost is £1 for the fortnight, for which sum 
very little work could be done, and it may well run 
to £2 or £3 for the whole period. In order to improve 
this unsatisfactory state of affairs, schemes have been 
devised for training women in domestic duties who 
should replace the handjrwoman. The woman so 
trained is termed the Home Help, and it is usual to 
make a somewhat lower charge than the actual cost 
of the scheme in order to induce the mother to employ 
the trained woman as against the untrained. The 
home help is strictly forbidden to undertake any 
maternity nursing or midwifery. She is not trained 
for maternity nursing, and it is illegal for her to do 


midwifery. She should not be employed at all on 
doctor's cases, lest she should come to think that she 
also can " manage without the doctor." It may be 
argued that at least she is better and more cleanly 
than the average handywoman, but the position is 
only a shade less black, and amounts to condoning 
ilhcit practice. Clearly there are many doctor's cases 
where the doctor is present, but it must inevitably be 
difficult to be reasonably sure that he will be able to 

The home help is usually under some form of in- 
spection : State grants in aid can be obtained by local 
authorities who provide these women, but at present 
the movement is not widespread as compared with 
the total number of births. 

Full pre-natal care could be given by the maternity 
departments of lying-in or general hospitals to those 
women who apply for midwifery aid. In some in- 
stitutions a good deal is already done, but the total 
amount done is small as compared with that which 
remains to be done. 

It must be again emphasised that ante-natal work 
does not only mean a medical examination of the parts 
most affected. This is, of course, an essential part of 
the work, but it is only a part. The work should 
include the treatment of any abnormal condition, 
advice as to daily life and habits, and also arrange- 
ments for the confinement both for mother and child, 
and instruction in infant care. The arrangements 
should be made by the mother herself, who should be 
told how to carry them out. 

The cost, however, is again a difficulty, and would 
be heavy if ante-natal care were made available for 
every woman attended by the maternity department. 
But the opportunity should not be lost. The work is 
of the utmost importance, and intensely worth doing. 
Some hospitals already make considerable provision 


for it, and others are realising its necessity. Grants in 
aid, up to one-half of the cost, are given through the 
Ministry of Health, and are of great assistance. Doubt- 
less, in the course of a few years, the need for ante- 
natal care will have become appreciated by the 
majority of the working-class women, and there can be 
little doubt that when due care is provided and accepted 
there will be a marked reduction of sickness and, it 
is to be hoped, of death among both mothers and 

The widespread campaign on the subject of venereal 
disease has doubtless emphasised i he need for ante-natal 
care. There appears, however, to be a tendency to 
assume that ante-natal care implies primarily the 
discovery and treatment of such diseases. This last is 
evidently of great value, but the incidence of venereal 
disease in the population at large is not known with 
any degree of accuracy. Although certain figures have 
been widely quoted there is no precise knowledge on 
this point, and it is difficult to see how any such informa- 
tion which could be considered reUable could be obtained 
under existing circumstances. 

Moreover, the mother does not always by any means 
suffer much herself from syphilis. It is the child that 
suffers most in such a case. The mother suffers much 
more and her health is more seriously impaired by the 
numerous ailments or pathological conditions which 
arouse little or no interest in the mind of the public. 
One is almost tempted to suppose that the widespread 
prevalence of other troubles as compared with the 
incidence of venereal disease is the cause of the indiffer- 
ence which is undoubtedly manifested, as compared with 
the interest betrayed in the whole question of venereal 
disease. At a recent conference on child welfare a 
note of warning was sounded by Dr. Eardley Holland 
on the danger of expecting too great results from ante- 
natal work in this direction. More, he thought, 


could result from improving attendance and care at 

Results are often hard to see and take time to 
become apparent. For many years the opponents of 
the child welfare movement asked repeatedly for 
figures, that is, for results, following on child welfare 
work. It was impossible to obtain such figures, 
but those most concerned felt sure that the work 
would bear fruit. Their hopes have been abundantly 
justified. While the truly satisfactory reduction in the 
infant death-rate cannot be attributed only to the child 
welfare movement, there can be no doubt that it has 
played a part, and the full effects may yet be to come. 

Ante-natal work will almost certainly be found to be 
of a similar nature. It is impossible to suppose that if 
the general level of health among pregnant women were 
improved, as it would be by systematic ante-natal work, 
it would not show favourable results. It is possible 
that some years will elapse before much good can be 
seen, and other factors will doubtless have their share, 
but this is inevitable. A movement which does not 
carry other factors in its train will not travel far and 
will probably produce very small results. 
. Ante-natal work must inevitably bring with it im- 
provement iu the clothing, feeding, and general hygiene 
of the mother and family, with resulting improved 
health. Some such improvement might admittedly be 
brought about by other means, such as the improvement 
in housing conditions, with corresponding domestic 
facilities, or by improvement in wages, with consequent 
improved feeding, etc. Some of these are already opera- 
tive and will doubtless be developed further. All means 
that can improve the health of the mother should be 
used as widely and with as little delay as possible. 


Attendance at Birth and Maternity Nursing 

The majority of all births occurring in the home are 
attended by mid wives, and the next largest number 
by doctors ; in addition, there are hospitals and other 
institutions where women can be taken for the con- 
finement, but the percentage of these cases is small 
as compared with those attended in their own homes 
by midwives or doctors, except in London.^ Here in 
the year 1915 out of 101,649 total registered births, 
32,661 were attended by midwives in their own homes 
and 38,146 by doctors. The remaining 19,656 births 
occurred in, or were attended from, hospitals. 

Outside London the number of births occurring in 
hospitals is small, and is negligible as compared with the 
births attended in the home. The question of hospital 
accommodation will be considered separately in the 
next chapter. 

The percentages of all cases attended by midwives in 
the home vary in different parts of the country, but are 
rarely less than 60 per cent, and frequently higher, 
reaching over 90 per cent, in a few towns. In some of 
the remoter districts where there is no midwife, all the 
cases are nominally attended by doctors. Since in some 
of these places the doctor is several miles away, it is 
hardly possible that he will be present at the confine- 
ment in every case. Doctors very often have to take 

^ For full figures see table on p. 7 of the Report to the Local 
Government Board by the Author (New Series 111), on the Provision 
of Midwifery Service in the Coxmty of London. 



responsibility for very unsatisfactory work by the 

Although this book deals primarily with the machinery 
of the services concerned, the position will be more easily 
understood if a few remarks are made as to the duties 
which fall respectively to the doctor and to the midwife. 
It has already been shown that in regard to ante-natal 
work there are two aspects — the one general or hygienic, 
that is, the food, clothing, etc. ; and the other curative — 
or the treatment of any abnormal condition. We do 
not know what percentages of cases may require treat- 
ment during the ante-natal period, since no figures are 
available for this country. Further, the figures would 
differ widely according as they were or were not taken 
to include all ailments or only those directly connected 
with pregnancy. 

The period of labour is relatively very short, extending 
from less than an hour up to many hours, or sometimes 
up to a few days. The general health of the mother 
undoubtedly exercises an important effect on the time 
of labour, but we are not at present in possession of 
any direct investigation upon this point. Fortunately 
nature still secures a high percentage of labours without 
complications, although probably many of them would 
be shorter and less painful if proper attention had been 
paid to the mother and if she had led a healthy life. 

Midwives are not allowed to undertake the handling 
of compUcations. They are recognised by statute for 
attendance in labour, but under their rules,- they must 
summon a doctor if any abnormal condition is found or 
should supervene in the course of labour. The same 
applies to any abnormal condition occurring after labour 
during the period of their attendance on the mother. 

The midwife is responsible for the management of the 
confinement and for the nursing of the mother and child 
during the whole period of her attendance. 

The doctor is, as has been already mentioned, usually 


summoned by the handywoman and not infrequently too 
late. She will probably make rough preparations for the 
confinement and will undertake all the nursing of the 
mother and child, which in a midwife's case is done by 
the midwife herself. The doctor, however, will deal with 
complications should they arise without further charge, 
unless a second doctor should be needed. Often there 
may be httle that needs attention, but sometimes both 
the labour and the recovery may be prolonged and 
entail much time and trouble to the doctor. 

Many people, fearing the additional cost of the doctor 
in the event of compUcations after they have engaged a 
midwife, prefer to engage a doctor and to put up with the 
inferior work of the handywoman. Others prefer a 
midwife on general grounds and risk the need for the 
summoning of a doctor. 

The midwife must attend her cases whenever she is 
summoned, and must not relax her care until the labour 
has terminated. After the labour she is responsible 
for the mother and child for ten days after the confine- 
ment, or longer, if the recovery is not satisfactory. 

The doctor attends at the confinement, and sub- 
sequently, if all goes well, will visit the patient three 
or four times during the following fortnight. The 
nursing is left to the handywoman. 

Good maternity nursing is of immense importance to 
both mother and child. The rate of recovery and, 
possibly, the subsequent health of both mother and 
child, will be affected by the service rendered. Training 
is required for the work, and it is deplorable that it 
should be permissible for doctor's cases to be nursed 
by any ignorant woman whom the mother may choose 
to employ. 

For normal cases and in existing circumstances, on 
the whole the attention given by a midwife is preferable 
to that given by a doctor and the handywoman. 

There should be a trained midwife for every case 


whether a doctor is engaged or not, and the best arrange- 
ment would be for both to be engaged, on the under- 
standing that the doctor did not necessarily attend 
unless some complication supervened ; but he or she 
should have been engaged early and should have ex- 
amined the patient at least once before the confinement. 
Of course the difficulty is the cost, but the matter is so 
important that every effort should be made to provide 
the best arrangements for attendance at childbirth. 

Unfortunately, at the present time, the midwives' fees 
are not ordinarily sufficient to enable them to spare the 
time and give their best work to the maternity nursing. 
A busy midwife, especially, is apt to devote insufficient 
attention to it. It is, however, most important that due 
time should be allowed for fc, and midwives should not 
undertake more cases than will admit of sufficient 
attention being devoted to the maternity nursing. 

The time necessary will vary according to the quick- 
ness or otherwise of the midwife. It is safe to say, 
however, that the average time in the early days after 
birth will be about an hour a day — sometimes three- 
quarters and rather less on succeeding days.^ Here, 
again, time is money, and if adequate care is given an ade- 
quate fee must be paid. Very few mothers can or will 
afford the necessary expense, although there are those 
who will prefer to pay rather more and get better service. 
The question of the fee is dealt with in Chap. XIX. 

Some associations employing midwives arrange for 
their midwives to attend as maternity nurses at a lower 
fee than when practising as a midwife. While the mid- 
wife has less responsibility, she has just as much work 
to do, and fully as much time is occupied. It is diffi- 
cult to see why a midwife should take a lower fee for 
Buch work, since, in the event of the doctor not reaching 
the patient in time, she has the full responsibihty. 

* C5f . p. 40 of Report to tho Looal Govornmout Boan^i by the 
Author (New Series HI). 



Also the provision of good maternity nursing is probably 
fully as important as the provision of trained aid at the 

The care of the infant and the importance of securing 
breast-feeding are matters to be borne closely in mind 
during the period after the confinement. Too often 
breast-feeding is relinquished after little or no effort, 
whereas it should be persisted in for a month or more 
before abandonment ; it is good for the mother and yet 
better for the child. The breast-fed baby is saved many 
of the risks to which its artificially -fed brother or sister 
is continually exposed. There is no means of replacing 
the natural food for the infant. Not only is it specially 
adapted for each species, but it is the means of the 
transmission of immunity from the mother to the child. 
During the first few days the child acquires immunity to 
all to which its mother is immune. The transmission 
takes place only in the first few days, but the value 
of breast-feeding does not thereafter become less. 
The birth-weight, which falls for a few days after birth, 
is regained more readily. The child has less risk of 
over-feeding, since it can take rather more breast-milk 
than necessary with comparative impunity, and its 
progress is, on the average, better than that of the 
artificially-fed infant. This does not refer to the 
question of weight. Babies can be made to put on 
weight very rapidly on artificial feeding, but the weight 
is not necessarily health ; the flesh is often flabby and 
the child has an undue amount of adipose tissue. While 
larger in size, it is frequently unhealthy, liable to colds 
and bronchitis, and is not infrequently rickety. The 
smaller child, with firm flesh and rounded but not fat 
limbs and body, is far healthier, and is ii\finitely more 
frequent among breast-fed children than among bottle- 
fed ones. In fact, it is doubtful whether any artificially- 
fed child exhibits the same satisfactory conditions as a 
healthy breast-fed one. Also, many weakly children, 


wlio would almost certainly die on artificial food, are 
saved by breast-feeding. 

The value to the mother of a healthy baby is immense. 
A healthy child does not cry, and will sleep well or lie 
quietly in its cot, always provided that it is not spoilt 
by continuous dandling. Some attention is good for it, 
and aids its mental development, but excessive petting 
or dandling renders it nervous and fretful. 

Too frequent feeding is a further trouble in many cases. 
The child that is fed every two hours dming the day and 
once at least during the night, usually acquires indiges- 
tion, and is fretful, wakeful, and irritable — in truth, the 
digestive system has no rest, and resents the continuous 
work. The mother's system resents it too, and, not 
infrequently, the loss of the milk supply results. It is 
very important that the child should be hungiy, and 
should empty the breast when fed. The first milk which 
comes is very poor in fat, and the last milk very rich. 
This latter is lost when the child is not hungry, as is the 
case when it is fed every two hours. The child then 
does not obtain its proper nourishment, and the gland, 
not being emptied, tends to cease functioning. The 
final result is a weakly baby, due to insufiicient fat in the 
food, and a gland that is said to be incapable of function- 
ing. The milk is found not to " suit the baby," and the 
bottle is instituted, when, since it gets more fat by this 
process, it begins to improve. The improvement is put 
down to the bottle-feeding, whereas the whole trouble 
has been caused by too frequent feeding at the breast. 

The majority of babies do well on four-hourly feeds 
during the day with an eight-hourly interval at night. 
A few do better on three-hourly feeds during the day and 
eight-hours interval at night, while premature or very 
delicate children will require special feeding arrange- 
ments. The long interval at night is very beneficial to 
both mother and child. Adequate uninterrupted sleep 
is obtained, which is of great value for both of them/f]-;;;^ 


Again, cleanliness in the newly-born child is important. 
Opinions are becoming somewhat divided as to the 
advisability of washing the child immediately after 
birth, as is the present general practice. The child 
enters the world with a warm layer of grease over its 
body, and the removal of this layer may be harmful. 
Probably it was intended as a protective coating for the 
first few hom-s after the infant's entry into a cold world. 
After the first few horn's, however, the infant should 
certainly be kept scrupulously clean. The cut end of 
the umbilical cord is a wound requiring attention, just 
as does any other wound. Too frequently trouble 
arises owing to neglect, and the resulting damage to the 
infant is almost certainly underestimated. It is prob- 
able that the subsequent occurrence of an umbilical 
hernia — a trouble far too common in this country — is 
largely attributable to neglect of the umbilical cord. 
Lack of cleanliness in other parts may give rise to skin 
troubles which retard progress. Again, cleanliness is 
essential for the mother. It is true that a certain 
number of woman do recover in spite of much lack of 
the most elementary cleanliness. But it is a grave risk, 
and one which need not be run. Moreover, recovery is 
undoubtedly hastened by a proper care of the body. 
It must be remembered that there is a wound surface 
here too, and care is required to prevent infection, 
a condition of great gravity in the woman after labour, 
and known as puerperal fever. It is hoped that this 
short digression upon some of the points connected 
with the care of the mother and child may be sufficient 
to emphasise the necessity for training on the part of 
whoever is to be responsible. 

On Sending for Medical Aid by Midwives. — In the 
event of any complications intervening in the course of a 
case, the midwife is required under her rules to advise 
the father, or other responsible relation, that medical 
aid is necessary. Ordinarily, the family attendant 


should be sent for, but, in the event of emergencv, it 
may be necessary to send for some other doctor. 
Many families have no regular attendant, and mar have 
no predilections. In this case, the midwife will exercise 
her discretion as to the doctor summoned. 

Great difficulty has arisen and considerable hardship 
over the question of the payment of the doctor's fee. 
The position has been improved by the Midwives Act of 
1918, but is not yet quite satisfactory. A doctor who 
is summoned to attend in an emergency may have to go 
out at night, and the case may last many hours, and 
require further attendance on subsequent days. There 
can be no question whatever that the doctor is entitled 
to a fee, and that such a fee should be adequate. The 
father may be in a position to pay the midwife's fee, 
but not the doctor's fee as well . The rules had not long 
been in force before trouble arose and representations 
were made. It was then agreed by the Local Govern- 
ment Board that the fee should be paid by the Poor 
Law Guardians if it was found that the father was 
unable to pay. Some guardians insisted that their 
district medical officer should be summoned, and others 
agreed to pay the fee of any doctor called in, or such 
part of the fee as the parent might be unable to afford. 
It is not necessary at the present time to investigate 
the causes which rendered this arrangement of little 
value. That it was so, is clear from the great demand 
for a revision of the position . This demand caused power 
to be given (see the Midwives Act of 1918) to local 
supervising authorities to pay the doctor's fee if the 
patient or her husband, or other persons, could not do so. 

In a great many cases the doctor came on receipt of 
the summons, for either no fee, or for a very small fee. 
While, no doubt, there are cases when the doctor has 
grumbled, or when due time has not been given, it 
must be remembered that the receipt of a fee has been 
uncertain in very many cases, and that, in innumer- 


able instances, the greatest care and attention have 
been given. Again, many midwives have themselves 
guaranteed the doctor's fee, or have agreed to receive 
a lower fee for themselves. In fact, the position was 
fraught with hardship for all concerned, and a remedy- 
urgently called for. 

A few towns, notably Liverpool and Manchester, had 
instituted schemes for the payment of the doctor's fee, 
either in whole or in part, that at Liverpool being 
singularly successful. The Notification of Births (Ex- 
tension) Act of 1915 gave permission to spend money 
on the service, and the Local Government Board 
sanctioned schemes put forward by local authorities 
in different parts of the country. The aid was only 
to be given to " necessitous " cases, and the difficulty 
of definition of the term gave rise to reluctance on 
the part of some local authorities to inaugurate a 

The Midwives Act of 1918 gave power to the midwife 
to call in medical aid when required under her rules, 
and laid upon the local supervising authority the duty 
of paying " to such medical practitioner a sufficient fee, 
with due allowance for mileage, according to a scale to 
be fixed by the Local Government Board." ^ It also, 
however, gave power to the local supervising authority 

^12. The Board have fixed the following scale for the purpose 
of this section : — 

(1) Attendance at confinement requiring opera- 

tive assistance and subsequent necessary 

visits during the first 10 days . . ..£220 

(2) Attendance at confinement without operative 

assistance and subsequent necessary visits 

during the first 10 days . . . . ..110 

(3) Assistance for the administration of an 

anaesthetic .. .. .. .. ..110 

(4) Any visit not covered by (1), (2), and (3) 

including any necessary prescription : — 

Day (8 a.m. to 8 p.m.) 3 6 

Night (8 p.m. to 8 a.m.) . . ..076 

with the addition of the mileage fee usual 

in the District. 


to " recover the fee from tlie patient . . . unless 
it be shown to their satisfaction that the patient . . . 
is unable by reason of poverty to pay such fee." This 
clause, which appears to be wholly favourable to the 
midwives, has, however, proved a double-edged weapon 
in the hands of a large supervising authority. This 
body appointed inspectors to visit all cases where a 
notification had been received from the midwife that 
she had sent for medical aid, and the parent's income 
was inquired into. The result was that many of the 
patients threatened to engage a doctor only in future, 
and not a midwife, and the midwives sent a deputation 
to the council concerned pointing out the seriousness 
of their position. 

The tendency will almost certainly be towards paying 
the whole fee without inquiry. Some supervising 
authorities do not appear to worry unduly about the 
recovery of the fee, and it is probable that the cost of 
the recovery would absorb a considerable part of the fees 
repaid. It is hoped that the doctor's fee will soon come 
to be paid by the local supervising authority in all 
cases when summoned by a midwife, without inquiry 
into the patient's means. 

The percentage of cases in which midwives sent for 
medical aid before the passing of the Act has been 
estimated by various people. For the large towns, the 
average percentage when help was sought for the mother 
is apparently between 8 and 10 per cent, of all cases 
attended by midwives. The figure varies considerably 
between the different towns, and is lower in the country 
areas. The figures for London for 1918 show that 
medical aid was sent for in 8 per cent, of all cases attended 
by midwives.^ The midwives will be influenced in send- 
ing for the doctor in cases of a less degree of urgency by 

* See pp. 81 ei «eq. of Supplement to the 44tli Annual Roport 
of the Medical Officer to the Local Qovernment Board fur 1914-16 
on Maternal Mortality. 


the distance the doctor may have to come. It will be 
very interesting to note how far the figure is affected by 
the schemes for payment of the doctor's fees by the 
local supervising authorities. 

The present training of a midwife does not place her in 
a position to do more than attend a normal confinement. 
Doubtless many of the more experienced midwives are 
fully capable of dealing with certain abnormal conditions. 
But it would be impossible to make regulations for those 
who have undergone the same training, whereby addi- 
tional powers were allowed to those of experience, but 
without further test. If midwives were to be allowed 
to do some of the work now done by doctors, a much 
longer training would be necessary, and the whole 
position would need very careful consideration. It 
would, in fact, amount to a recognition of a specialised 
but inferior grade of medical practitioners, as it would 
be impossible to require more than a two years' training 
at the outside. Although arrangements of this nature 
do exist in other countries, it is doubtful how far it would 
work satisfactorily here. The whole question is very 
thorny, and fraught with grave difficulties at present. 

Maternity Benefit. — The Maternity Benefit of 30s. 
payable to the mother was inaugurated as a part of the 
National Health Insurance Act of 1911. It was a 
recognition of the value of children, and formed a sort 
of recompense to the mother. It appears originally to 
have been somewhat vaguely intended to provide the 
fee for the doctor and midwife, or for both of them. In 
1911 a fee of 15s. would have been regarded as a good 
fee for a midwife, and many doctors were prepared to 
attend when summoned by a midwife for a similar fee. 
Thus the 30s. Maternity Benefit might have been re- 
garded as a sort of insurance to the mother against the 
expense incidental to childbirth. 

In many cases the money has not been spent directly 
on payment connected with the confinement, but has 


been used for general family purposes. This has caused 
a good deal of criticism. It would, however, seem un- 
reasonable to require that the actual money paid over 
should necessarily be used for the expense of the con- 
finement, since, without doubt, other money spent before 
the confinement would have been available for general 
purposes, such as rent, boots, etc. If, therefore, the 
cost of the confinement has caused delay in purchasing 
other goods, there seems no real objection against using 
the Maternity Benefit money for those purposes when 
it is paid over after the confiiaement. 

Undoubtedly the midwives' fees have been raised as a 
result of the Maternity Benefit, and there is general 
agreement that better provision is now made for the con- 
finement than was formerly the case. It must be re- 
membered that the 30s. paid as the Maternity Benefit 
does not nearly cover the total cost of the confinement. 
The cost of even simple arrangements will amount to not 
less than from £3 to £4, and may well reach a higher 

Whether the improvements noted have justified the 
cost of the Benefit to the State can hardly be determined 
with any approach to accuracy, and its consideration is 
entirely beyond the scope of this work. 

There is no doubt, however, that the amount of money 
which will be required for the various forms of care for 
children in the near future, will be considerably in excess 
of the amount of the Maternity Benefit. One of the real 
needs of the moment is improved provision and arrange- 
ments, including alterations in the law, for the present 
unfortunate unmarried mothers and their children. 


The Provision of Maternity Care by Institutions 

In the preceding chapters the work which should be 
undertaken in connection with every birth, and the 
duties falling respectively to the doctor and midwife, 
have been briefly described. 

No special remarks have been made as to the 
place of the birth, although it has been assumed 
that the birth would take place in the mother's own 

Any detailed exposition of the work of in-patient 
maternity hospitals or other institutions would be un- 
suitable in a work hke the present one. Beds for mater- 
nity cases are, however, an essential part of any mid- 
wifery service, although, fortunately, the number of 
mothers for whom hospital aid may be regarded as neces- 
sary form only a small percentage of the whole. If 
about 8 per cent, of all cases require medical aid, it 
may be assumed that only a proportion of these should 
have been placed in a hospital for their confinement. 
Medical aid is sought for a large variety of conditions 
which can hardly be regarded as involving the need for 
hospital care. It is probable that, if beds were avail- 
able for 5 per cent, of all births, practically all cases 
requiring hospital aid could obtain it. 

For many years there have been institutions where 
women could go for the confinement. The Poor Law 
provided faciUties, and there were also maternity hos- 
pitals. It is probable that the really destitute alone 


availed themselves of the Poor Law service, and in- 
asmuch as it forms only a small fraction of the total 
work undertaken, it need not be considered further. It 
should, however, be remembered that beds in Poor Law 
institutions are available for this purpose all over the 
country, and that cases of comphcations are not in- 
frequently sent in to the Poor Law infirmaries in default 
of other accommodation. 

In London there is a fair provision of maternity beds 
in hospitals, although this statement requires some 
quahfication later. The accommodation consists of 
those hospitals which take maternity cases only, and of 
maternity wards in the general hospitals. It has always 
been recognised that medical students must have some 
experience in normal midwifery, but general hospitals 
have not felt greatly drawn towards the allocation of 
beds for such cases. This is easy to understand. There 
is an acute shortage of beds for all forms of medical and 
surgical cases, under existing arrangements, and it was 
felt that these were more pressing than normal mid- 
wifery cases. Therefore, for the most part, such beds 
as were available for midwifery were rightly reserved for 
comphcated cases. Of recent years, Oxford and Cam- 
bridge have required that their students, who must take 
a certain part of their clinical work in London, shall 
only attend those hospitals where some beds are set 
apart for midwifery work. Only four hospitals have 
responded by providing maternity wards where both 
normal and abnormal cases are admitted, and where 
medical students can be taught the practice of normal 
midwifery. Three others have a few beds which are 
reserved for the instruction of midwives. 

Adequate in-patient provision for training students is 
not made in a number of the medical training schools, 
but there will be some increase in the number of beds in 
the near future. This has been strongly recommended 
by a special committee appointed to consider the training 


of medical students in midwifery.* Full details are 
there given of the total present facilities in the Training 
Schools; details as to the beds available, and cases 
treated by the maternity hospitals, can be obtained 
else where. 2 

As late as the end of 1919 there were in the whole 
of the general hospitals of London 117 beds reserved 
exclusively for obstetric cases. In addition, a certain 
number of gynaecological beds were used for compli- 
cated cases of midwifery. In 1916 the eight special 
maternity hospitals provided the vast majority of the 
beds, amounting in all to 320, out of the total of 437. 
This total number of beds provided for aid in relation 
to 9089 births, which occurred in all the institutions 

There were, in addition, some small self-supporting 
lying-in homes kept mainly by private midwives, where 
a few hundred births occurred annually. Their numbers 
are, however, negligible for the present purpose. Since 
1916 a number of other lying-in homes have been 
opened by a few of the borough councils under the 
maternity and child welfare schemes. 

Investigations carried out in 1916 ^ showed that about 
9 per cent, of all births in London occurred in hospitals. 
It is very unlikely that the figures for those really needing 
hospital care are as high as this, and it is probable that 
5 per cent, would be a more correct figure. It would 
appear, therefore, that the actual number of beds avail- 
able is sufficient for the real medical needs of the pop- 
ulation, as well as for a number of persons who come from 
other parts of the coimtry to be confined in the London 
hospitals, if all these beds were reserved for abnormal 
cases, or for those where complications might be antici- 

^ Proceedings of the Royal Soci'ty of Medicine, June 1919. 

* Report to the Local Government Board by the Author (New 
Series 111). 

' Report to the Local Government Board by the Author (New 
Series lJl),pp. 11 and 12. 



pated. But the majority of the cases admitted are 
normal, and the women ask for admission to the hospital 
because they feel that it will be more convenient, for 
other reasons of a private nature. Further, the large 
maternity hospitals draw their patients not only from 
all parts of London, but from other parts of the country. 
There is no systematisation either in regard to the nature 
of the case or to the district served. There are some 
districts which have two or three hospitals with mater- 
nity beds within a few minutes' walk, while in other less 
central parts no maternity beds are available within 
several miles. 

All the maternity hospitals, and all the general 
hospitals with medical schools attached, have out- 
patient maternity departments for the training of their 
pupil- mid wives and medical students. In some of the 
hospitals a careful bifting of cases is undertaken when the 
patient comes up to book, in order to ascertain the pos- 
sible need for in-patient care, and cases from the out- 
patient department requiring in-patient care are usually 
accommodated in the hospitil. 

While provision is made for at least the most urgent 
cases, in practically all the hospitals with out-patient 
maternity departments a great many normal cases are 
given in-patient care, and it is often difficult for general 
practitioners to obtain admission for urgent cases 
occurring in their practices. No attempt is made to 
serve the general interests of London as a whole — each 
hospital is an independent unit, responsible to no one, 
except, possibly, to those by whose contributions it is 
maintained. No charge is made for the in-patient care, 
although in some hospitals patients are encouraged to 
contribute a sum whicn is inevitably small as compared 
with the cost to the institution. 
; Some nominal charge is made in connection with the 
attendance in the homes at certain hospitals for those 
who can pay it, and it is usually understood in theory, 


at any rate, that women who are able to afford a midwife 
or doctor should not be attended in their own homes 
free of charge. 

While, no doubt, some general benefit results from the 
out-patient midwifery work of the hospitals, it is to be 
feared that, to a great extent, it serves to keep down 
the level of the midwifery and doctors' fees in the 
district, and thus inevitably to maintain a low level of 
practice. If the work undertaken by the hospital were 
always on a high level, at least it would set an example 
of good work, but much improvement is needed in that 
undertaken in connection with some of even the largest 
hospitals , both on behalf of the women and of the students 
in training. Maternity nursing is of course provided for 
the in-patients, but not always for the out-patients. 
When the cases are attended by the medical students, 
usually no maternity nursing is provided, except in 
specially bad cases. Two London hospitals provide 
maternity nursing for all out-patient cases, but, so far, 
this is not provided as a routine measure by the other 

When the cases are attended by pupil-raidwives, 
under the charge of a trained midwife, maternity nursing 
is undertaken, and the quality of the care bestowed will 
depend upon the ideals the department may have or be 
able to execute. 

Outside London there is a great dearth of hospital 
facilities for maternity cases. In many of the large 
towns there is no accommodation at all except in the Poor 
Law infirmary, while beds in the smaller towns and in 
rural or scattered urban areas are so rare as to be of no 
account in dealing with the needs. 

During the last few years a number of small maternity 
hospitals have been opened chiefly by the local 
authorities and by the aid of State grants. These will 
be most valuable and mark an improvement in our 
present condition. 


Many more maternity beds are, however, needed out- 
side London, if even 5 per cent, of all births are to receive 
in-patient care. 

The last few years have witnessed the rise of a school 
of thought which considers that all births should, if 
possible, take place in an institution. There has been 
much outcry about the housing conditions of the 
country generally, and it appears to be assumed that all 
houses are unfit for the occurrence of a birth. While 
no doubt there are a great many houses which are un- 
suitable for confinements, especially where the present 
shortage of houses is most felt, there is no need to suppose 
that the majority of births cannot occur in the home. 
Again, the absence of the husband on war service, and 
the increased cost and difficulties of living, etc., have 
made many women feel that they would prefer to be in 
a home where they were looked after. A number of 
nursing homes have sprung up to meet this need, and so 
long as they are self-supporting they are clearly a benefit 
to those who wish to take advantage of them. 

But the outcry sometimes raised for in-patient care 
in homes and hospitals for all births is ill-considered. 
In the fijst place the cost would be prohibitive. It would 
be impossible for more than a relatively small proportion 
of the women concerned to pay the fees which would 
be necessary to make the institutions self-supporting. 
Before the war the most economical figures for maternity 
beds worked out at a cost of approximately £5 per 
patient for normal cases. This figure does not include 
any allowance for initial expenditure. The cost will 
certainly have risen very considerably at the present time, 
but precise figures are difficult to obtain. A maternity 
bed can accommodate from 17-20 patients during the 
year, so that if all cases were to be given in-patient care, 
at least one bed to every 20 births would be necessary. 

Many women, however, much prefer to be confined 
in their own homes, and many others cannot leave their 



husbands and family. Although the mother may be 
unable to get about, she can, nevertheless, give directions 
and enable the house to be carried on, and the woman 
who comes in to help will look after the home if the 
mother is there. The father who goes out to work can- 
not look after the children himself, and there may be no 
accommodation for a woman other than the mother of 
the family. In this case arrangements must be made for 
boarding the children elsewhere. If these arrangements 
are made out of public or private funds, as is suggested 
at the present, then no doubt the cheapness will be an 
attraction to the parents, as it will cost less than if the 
confinement is at home. But it will prove a heavy drain 
on the funds in question and is, in many cases, an un- 
necessary expense. 

Further, there is no reason why parents should be 
spared all the trouble of a confinement. It is often very 
beneficial for the father to have at least some knowledge 
of what his wife is called upon to go through. 

If it be a question of inadequacy of home accom- 
modation, it will be preferable to aim at improving this 
rather than to demand the opening of expensive lying- 
in homes. 

It is surely better to make efforts and spend money 
on improving home conditions rather than on the pro- 
vision of costly buildings and appliance-s which should 
only be necessary for abnormal cases. Cleanliness and 
care are, of course, essential, but these should be 
procurable in the home of every citizen. Hospital 
accommodation is hopelessly inadequate in the provinces 
for even the severe cases, and it seems premature to 
discuss, as is sometimes done, the erection of hospitals 
for all normal cases. Let effort rather be directed 
towards the prevention of complication by ante-natal 
care and the securing of adequate conditions in the 
home for uncomplicated cases, with hospital facilities 
for those cases where complications may be anticipated 


and are not preventable in the light of our present 

The fear of the supervention of sepsis appears to be 
the chief feature in the minds of some who advocate 
in-patient care. If precautions were resorted to as 
above mentioned, especially the elimination of septic 
foci in the mother, there would be less risk than is at 
present the case. Even now, in admittedly unsatis- 
factory conditions, it is astonishing how seldom septic 
trouble supervenes. Additional facilities for supplying 
sterili?ed articles to doctors and midwives would be a 
valuable part of any maternity scheme for a district, 
and could be arranged with comparatively little trouble 
and not much expense. 

But it should be remembered that child-bearing is not 
a pathological condition, and accentuation of the diffi- 
culties and possible dangers of childbirth are not likely 
to encourage the young prospective mother. Many 
women are most unwilling to enter any institution, and 
if they felt that childbirth was so serious a process that 
this was necessary for safety, the effect on the birth-rate 
would probably not be long delayed. 


On the Present Provision of Midwives 

It will not be necessary to deal further with the medical 
practitioners as a part of the midwifery service, not 
because they do not form a very impo tant part of that 
service, but because there are no special further points 
to be made. The country is fairly well provided with 
doctors, although, in rural districts, many patients would 
be difficult to reach without a very good horse or a motor 
car, either of which, however, enables the doctor to 
attend patients at a considerable distance from 

The midwife who attends for the maternity nursing, 
and who should devote a sufficient time to each patient 
to give the required aid, can work only a comparatively 
small area, even with the aid of a bicycle. A great many 
midwives use bicycles, but their earnings do not admit 
of any other form of private conveyance. A midwife 
can probably take cases about 2 J miles in every direction 
from her home, but it is arduous, and any greater 
distance would be too great a physical effort for most 
women, since there will be work nearer home and in other 
directions as well. 

There is not a sufficient provision of midwives in 
many parts of the country. In some of the large towns 
there are, it is believed, a few midwives more than may 
be necessary for the needs of the inhabitants, but in 

the country places there is often no midwife, and in some 



places there is a definite shortage. The causes of the 
shortage are economic in character, and a consideration 
of them leads to some very interesting and important 
aspects of the service. The total number of midwives 
on the roll is given each year in the Report of the 
Central Midwives Board. This figure, however, includes 
considerable numbers of qualified midwives who are 
not practising and have no intention of practising. 
Many are married and have no time, and others have 
taken up various forms of work where their training 
will be of value to them, but where they do not under- 
take any midwifery. Health visitors fall into this 
category, as also do a large number of women who work 
as private maternity nurses in well-to-do families under 

The numbers on the roll for some of the years are 
shown below : 





March 31 










The number of un- 
trained midwives in 
practice was believ- 
ed to be largely in 
excess of the trained. 





About 53*5 per cent, of 
the untrained are in 
practice, and 22*1 
per cent, of the 





About 20'5 per cent, of 
the trained, and 48'4 
per cent, of the un- 
trained are in prac- 

* From the Reports of the Central Midwives Board. 


The number of women on the roll evidently has no 
relation at all to those in practice. It does show, how- 
ever, that there is a large reserve of trained midwives 
available for practical work to meet the shortage, if they 
can be persuaded to practise as midwives. 

The only way in which any estimate of midwives in 
practice can be obtained is from the lists sent each year 
by the local supervising authorities to the Central 
Midwives Board. But these lists do not give an alto- 
gether correct figure by merely adding the numbers, 
because a fair number of midwives live near the bound- 
aries of adjacent authorities and must notify their 
intention to practise to each authority if they are likely 
to be employed on any case within the area of that 
authority. If they do not notify their intention, and 
afterwards undertake one or more cases in that area, 
they are liable to be fined rather heavily. 

Hence, if the numbers of midwives sent in by all the 
local supervising authorities are added, certain mid- 
wives will be included two or even three times in the list. 
Again, some of the lists make no serious pretensions to 
accuracy, because the expenses of the Central Midwives 
Board were, until 1919, charged on the various authori- 
ties in proportion to the number of midwives returned 
as notifying their intention to practise. The Act of 
1918 now distributes the charge in proportion to the 
population, and it is possible therefore that some modi- 
fication may be expected in the lists of some of the poorer 
districts. The Central Midwives Board comment, in 
several of their reports, upon the inaccuracy of the lists 
from certain authorities. The larger authorities have 
usually returned accurate lists, although where 
the Midwives Act has not been strictly administered 
it is not unlikely that such lists were not quite 

In 1914 an estimate of midwives in practice was made 
by the Local Government Board from the figures ob- 


tained in the reports of the local supervising authori- 
ties. The figures thus reached were as follows : — 

Total number of midwives in practice . . . 14,312 

Total number of trained midwives in practice . . 6,936 

Total number of untrained midwives in practice . , 7,376 
Total number practising in the Counties (including 

London) 11,022 

Total number practising in County Boroughs . . 3,290 

In 1915, 1916, and 1917 the Report of the Central Mid- 
wives Board gives the following : — 

1915. 1918. 1917 
Total number of midwives in practice 12,087 11,807 11,449 
Total number of trained midwives 

in practice 1 .... 6,754 6,981 6,896 

Total number of untrained midwives 

in practice .... 5,333 4,826 4,553 

Evidently the number of untrained women in practice 
is diminishiiig with considerable rapidity, and the number 
of trained midwives in practice, in spite of a rapid 
increase in trained midwives (as shown by the figures on 
p. 16>), is remaining fairly constant. As a result, the 
total number in practice is steadily decreasing. 

Each midwife presenting herself for examination is 
required to state whether she intends to practise or not. 
The figures given in the Reports of the Central Mid- 
wives Board show that in 1908-9 the number of those 
who intended to practise was 58 per cent, of all successful 
candidates. In 1911-12 it had fallen to 48-8 percent., 
and in 1915-16 to 47-8 per cent., but in 1917-18 the 
number rose to 54 6 per cent. In the year before there 
had also been a slight increase over the preceding year 
when the midwives entering practice were apparently 

* These figures for trained midwives in practice include all those 
who are connected with institutions and are not inconsiderable in 
number. Thus, in 1915, out of a total number of 496 midwives 
who notified their intention to practise in the County of London, 
118 were coonoctod with some kind of institution for maternity 


being attracted to the towns. The increase in 1917-18 
was, however, due to a rise in the numbers intending 
to practise in rural areas. 

The cause of the increase in rural areas is, no doubt, 
due to the measures now being taken by county councils 
and county nursing associations to extend the mid- 
wifery work in their areas. For many years past the 
higher education committees of a number of county 
councils have awarded scholarships for training mid- 
wives, for the county nursing associations. A few 
associations have their own training homes, but others 
arrange for training with different training institutions. 
The midwives are trained free of all charge to themselves, 
but they must sign a contract to work for, generally, 
three years after training in any part of the county to 
which they may be allotted. For some years past the 
Local Government Board has made grants in aid of 
midwifery to the county nursing associations, and has 
also repaid 50 per cent, of any subsidies granted by 
county councils to maintain and extend the midwifery 
provision in the county. The efforts thus made are 
meeting with a good deal of success, and at least one 
county has no district without a midwife, and several 
others have nearly reached that desirable state. 

In general, however, the position gives rise to anxiety, 
since if a midwife is too busy, she will not be able to 
carry out that good work which is essential for the health 
of the mother and child. 

There is one primary cause which is producing the 
shortage of midwives, and that is the simple one that the 
fees paid by the patient are too low to enable a midwife 
to carry on her work properly and yet earn a reasonable 
livelihood. In the years before the Midwives Act of 
1902, many midAvives only earned 5s. or perhaps less for 
a case, but the service rendered was also sUght. The 
work now required of a midwife is exacting and ever- 
increasing. She has considerable clerical work to do, 


keeping registers and sending forms to the local 
supervising authority, and she is continually being 
called upon to render more service to each case. The 
ante-natal work alone will, if properly done, demand a 
fair proportion of her time. The fees, however, do not 
rise in due proportion, and in 1915 the average fee was 
probably somewhere between 10s. and 15s. in the large 
towns. A few midwives charged higher fees, but others 
again received less, and bad debts had always to be 
allowed for, especially among the poorer class practices. 
The rise in fees up to a possible 15s. has been mainly 
brought about by the Maternity Benefit, and a further 
rise in fees has taken place with the increase of wages 
paid during the war. A fair number of midwives in 
fairly good class practices obtain fees of ITs. 6d. to 21s. 
It is reckoned that, in order to give sufl&cient attention 
to each case, a midwife cannot undertake more than 
150 cases per annum, and, when the population is scat- 
tered, 100 will probably be the highest figure. Suppose 
that a midwife obtains even 15s. as an average per case, 
her income will be somewhere between £75-£112 as a 
maximum per annum. Out of this she has to pay for 
her apparatus, the washing of dresses and aprons, per- 
haps the upkeep of a bicycle, for a maid or some one to 
live in the house to receive messages while she is out, in 
addition to the ordinary cost of living.^ Evidently, 
the life offers no financial attractions at all, and it is no 
wonder that few trained midwives enter practice 
independently. Either they will work in connection 
with associations or hospitals where a fixed salary is 
guaranteed, or they must receive money from other 
Bources. The only possible source of money is that 
received by rates or taxes, namely, pubUc money. 

* For further intormation on this subject reference should bo 
made to Reports by the Author, in the Medical Officer to the Local 
Ootremmcat Board's Annual Report, 1914-16, Supjjlement, pp. 85 
tl »tq. ; and Report to the L.O.B. on the Provision of Midwifery 
Senriae in the County of London (New Series HI). 


Twenty-five shillings is generally regarded as the 
approximate fee a midwife should receive for her work 
for each case, including ante -natal work, which is usually 
reckoned at about 58.^ If 120 cases be undertaken on an 
average in the year, the midwife should have an income 
of £150, which certainly cannot be regarded as excessive 
in view of the requirements made. 

Various schemes have been put forward for the pro- 
vision of a midwifery service. For the most part they 
advocate either the appointment of so-called " municipal 
midwives," or that the municipality or the State should 
pay a capitation fee in some form or another to any 
midwife in practice. It is proposed that the municipal 
midwife should attend the cases in a certain district, 
or it might be that there would be a choice of two or 
three midwives for the mothers of each district. The 
proposal presents many practical difl&culties, and in the 
few places where it has been introduced it has not been 
found successful. 

As circumstances have altered very considerably since 
the proposals were put forward, it is hardly worth while 
to discuss them in detail. Any scheme now put forward 
would, of necessity, differ in many respects from those of 
the last few years. It is difficult at present to say how 
far the grants now available under the Ministry of 
Health may meet the situation (cf. the circular in 
Appendix III). 

Rural Midwifery. — ^A good deal has been already said 
as to the arrangements for rural midwves in connection 
with the work of county nursing associations. These 
associations do not themselves ordinarily undertake 
maternity work, but they assist and encourage the work 
of district nursing associations. The whole country 
has not by any means been provided with midwives, nor, 
until recently, has it been possible for any county to be 
entirely covered by village nurse- midwives. The grants 
^ With the continued gradual rise of prices, these fees are too low. 


now available from the Ministry of Health for the aid of 
midwifery enable the associations to extend their work 
very greatly. In small districts there is probably no 
better arrangement than the provision of a village 
nurse- midwife. There are, however, other less scattered 
districts where an independent midwife can almost 
obtain a livelihood, but where there is too much risk 
attached, and ordinarily no one will practise there under 
existing conditions. In such cases the county council 
can subsidise the midwife sufl&ciently to enable her to 
maintain herself in practice and thus provide a good 
maternity service for the district. Many schemes for 
completing the provision of midwifery aid are now 
being prepared, and it may be hoped that in a few years' 
time there will be few districts left unprovided with 
midwifery aid.^ 

The proposed arrangements for Durham County, which 
have been approved by the Ministry of Health, are of 
great interest, as showing the way in which provision can 
be made for the various types of districts in an area. 
Durham County contains a number of large villages, or 
small towns, where independent midwives can only make 
a doubtful livelihood. The scheme is given in full in 
Appendix VI (A). 

A fee is charged for the services of the village nurse- 
midwife, which varies in different districts, and depends 
also upon the circumstances of the patient. Sub- 
stantial assistance is, however, needed in order to main- 
tain the midwives. The assistance required varies 
from district to district, and it is impossible to give any 
average figure, since in the first place, in most cases, 
they are complicated by subsidies for other purposes — 
child welfare work, etc. — and further, the cost is so varied 
that no one figure can give any satisfactory idea of the 

* Arrangements for the paj^ent of grants in aid of midwifery 
for county nurning associationfl are set out in Oircular M. &, 0. 
W. 7 of the Local QoTemment Board. 



position. Leaving aside subsidies, the grants vary 
between £10 or less to £20 or more. 

Some idea of the cost of such schemes is given by the 
scale of pay of the Hertfordshire County Nursing 
Association, which became operative in 1918. The 
scale was then raised appreciably, and is higher than that 
in most other counties, although, no doubt, many of them 
will soon be raising their fees to similar levels. The 
full scheme is given in Appendix VI (B). 

The whole position cannot be regarded with any degree 
of satisfaction. It seems certain that the profession 
must be made more attractive, and that in order to do 
this, the money earned must be improved. 

Some assistance will be forthcoming in connection with 
the schemes of the various local authorities, and may 
possibly be sufficient to meet, at least, the most urgent 
needs. At present the schemes are, for the most part, 
in their early days, and prophecy would be unwise. 

The Board of Education have recently offered grants 
for the training of midwives, and this may help, and is, 
in any case, most welcome, but a slight reduction in 
the cost of training hardly compensates for a small in- 
come in the many years of work which will presumably 
follow the period of training. 


Infant Mortality 

So much has been written and talked about this 
subject that any lengthy handling of the question 
of infant deaths is unnecessary. No book on child 
welfare work could, however, be regarded as in any 
degree complete if some reference to it were not 

The movement, in its early days, was, as has already 
been mentioned, mainly directed to the prevention of the 
mortality among infants. The associations and societies 
which arose in this and other countries all assumed titles 
showing that they regarded their work as primarily 
directed to the reduction of infant mortality. One by 
one, as the work has developed, these organisations 
have changed their names. It has been realised that 
the work undertaken was in many ways distinct from 
what should be regarded as work for the prevention of 

In order to show how this has become evident it is 
necessary to deal with the more salient points concern- 
ing the mortality among infants. The infant mortality 
rate is the number of infants dying under one year of 
age per thousand infants born. The figures are ob- 
tained through the Registrar of Births and Deaths, 
and are collated at the office of the Registrar-General. 
Statistics give valuable information as to the general 
position on many matters, and indicate the directions 

in which work is required. 



The infant mortality rate must be regarded rather 
as an index of conditions as a whole, and not as affording 
specific information. Other figures are also important 
in connection with child welfare, especially the death- 
rate among children over one year of age. Discussion 
of the absolute reliability of any statistics used is un- 
necessary here, where it is proposed only to use the 
general trend of available figures to " point a moral 
and adorn a tale." 

Vital statistics are based on innumerable complicated 
factors, interwoven the one with the other, dependent 
upon the morals,thepsychology, the social and economic, 
the climatic, and all other conditions which go to the 
making of national characteristics. If one factor is 
taken alone, very erroneous deductions can be made. 
The following table shows the infant mortality rates for 
England and Wales, and the birth-rates ^ for the corre- 
sponding years are shown in the adjacent column : 


Infant Mortality Rate. 


























A superficial glance gives the impression that the two 
rates must be closely associated. No doubt this is to 
someextent the case, but, as a moment's reflection shows, 
the connection is indirect and not direct. While both 
have fallen, the fall is not parallel, the birth-rate having 
fallen more rapidly than the infant mortality rate. The 
primary causes of the fall in birth-rate before the war 
were no doubt due to the rise in the general standard of 

* The birth-rate is the number of infants bom per 1000 of the 



living, which rise was inconsistent with the possession of 
a large family. Hence, only among those classes whose 
demands on life were low was there an approach main- 
tained to the same birth-rate as in the middle of the last 
century. In all other classes of society the rate has 
fallen far more heavily than the general fall in the birth- 

During the war the birth-rate has fallen owing to the 
absence of a large proportion of the male population 
on war service. The war, with its increases in wages, 
has brought with it a rise in the standard of living 
out of all comparison great, as compared with the 
advance made in any previous period of 4-5 years. 
At the same time child welfare work has increased 
enormously, and there is good reason to believe that 
these factors, especially perhaps the last one, are re- 
sponsible for the fall in infant mortality to a greater 
degree than the birth-rate. 

The war has furnished an experiment on a colossal 
scale of the effect on infant mortality of the improvement 
in general social conditions due to an increase in wages. 
Some money has doubtless been mis-spent, but the 
immense improvement in the clothing and feeding of 
children generally at a time when other means of im- 
provement, such as housing and sanitation, were at a 
standstill, has furnished an object lesson which should 
be taken to heart for the future. 

There is some divergence of view as to the merit of 
a low infant mortality rate. Professor Karl Pearson 
and others regard the production of unhealthy infants 
as eugenically unsound, and believe that infant mort- 
ality 18 Nature's way of removing the unfit. Doubt- 
less this is true to some extent, and the care and labour 

^ Those interested should consult the figures for different pro- 
fessions given in the Annual Reports of the Registrar-General, 
and in the census returns, and the Report of the Oommission on 
the Birth- Rate. 


bestowed upon the preservation of lives of no obvious 
value, but of great expense to all concerned, give cause 
for serious thought, but will not be further discussed 

Preventable and non-preventable. — The early work 
among infants soon showed that very simple measures 
were su£&cient to effect a reduction in a high 
mortality rate. The work of Budin,^ and the figures 
given by him, showed that a great fall in infant death- 
rates occurred in nearly all towns where a milk depot 
and infant consultation had been established. So 
great and so rapid was the fall, that it was believed 
that a panacea had been discovered. The fall was 
mainly in deaths from diarrhoeal diseases, which are in 
large part due to feeding with contaminated food, or 
to some other source of direct or indirect bacterial 

Infant deaths became divided into the two classes — 
preventable and non-preventable. These distinctions 
nave proved to be entirely artificial. As knowledge 
increases it is found that many tjrpes of cases, hitherto 
regarded as non-preventable, are really preventable. It 
would be a bold step at the present time to go further 
than the assertion that certain causes of death are non- 
preventable in the light of our present knowledge. 

It is now necessary to give some short account of the 
information gained by the analysis of the infant 
mortality rate. 

If the crude figures of infant mortality be taken it is 
found that the causes of death can be classified into a 
few main groups : 

1. Wasting diseases (atrophy, debility, marasmus 
and prematurity). 

2. Diarrhoeal diseases. 

3. Bronchitis and pneumonia, 

^ The Nursling, trans, by Maloney. Caxton Pub. Co. Manuel 
Pratique d'Allaitement. Paris t Dom. 


4. Measles and whooping-cough. 

5. All other causes. 

A comprehensive analysis of the figures for 241 urban 

areas wa; published in 1913 ^ which showed that, taking 

the figures for the causes of death in the four preceding 

years 1907-10, the percentage due to the main causes 

was as follows : 

Causes. , Percentage of aU 

deaths under one year 

1. Wasting diseases and premature 

2. Diarrhceal diseases 

3. Bronchitis and pneumonia 

4. Measles and whooping-cough 
6. All other causes 






Analysis of the ages of the children at death, in the 
same area and for the same period, showed that a very 
large number of the deaths occurred under one month 
of age, which suggests that those deaths were due, in 
large part, to causes operating before birth. 

0- 1 week 24'3 per 1000 of all births under one year. 
0- 1 month 40*2 „ „ „ 

0- 3 months 63'5 „ „ „ 

3- 6 months 22-9 „ „ „ 

6-12 months 34*2 „ „ „ 

The mortality rate decreases as the length of life 
increases — in fact, the child's chances of survival 

The deaths during the first month (neo-natal period) 
will include a large proportion of those falling in group 1. 

No further comprehensive report has been published 
by the Local Government Board, but the reports avail- 
able for the various large towns and counties show that, 
while the general rate of infant deaths has fallen, the 
rate for this group of causes shows an inadequate re- 

* Supplement to the Report of the Medical Officer to the Looal 
Ooverament Board, 1912-13. Second Report on Infant Mortality, 
pp. 82 et $eq. 


duction as compared with the total reduction of the 
infant death-rate. Thus, if the figures for one large 
town be taken, they are as follows : 








of Total. Rate. 

of Total. 

Rate, of Total. 

Deaths in 

Group 1 61 '4 

33-6 31-2 


32-0 28-8 

Infant death- 

rate under 3 

months of 

age . 72-0 

46-6 61-6 


60-2 54-0 

Total infant 


rate . . 154 



and these are presumably typical of other places in 
the country.^ 

In rural districts the deaths occurring imder these 
headings give as a whole a higher relative percentage 
than in the towns, since the death-rates from other 
causes are lower. Speaking generally, it is found that 
the death-rate in the rural areas is considerably lower 
than in the towns. The fall in rate has apparently been 
most marked in the towns, certain of which are rapidly 
approximating to the figures for some rural districts. 
Rural districts, however, differ very widely in their con- 
ditions, and it is unwise to attempt any close comparison 
between different areas. 

If ante-natal work becomes general, and an adequate 
midwifery service is set up, the number of deaths under 
three months should soon begin to fall. The fall may not, 
however, be entirely attributable to this work, since in all 
cases where one improvement is made, it usually carries 
with it improvement in other conditions as well, such as 

* In this particular town it is noteworthy that, while the total 
infant death-rate has undergone a remarkable reduction, the deaths 
under three mouths of age have decreased so much more slowly 
in proportion as to raise the percentage of deaths in this period 
In relation to the whole number. 


improved sanitation, etc. Often it is the joint action 
whicli causes the effect. 

Group 2 (of diarrhoeal diseases) shows a high rate in 
many of the towns, especially in industrial towns in the 
north of England and in South Wales. In the north of 
England the sanitary conditions are very unsatisfactory 
and urgently require improvement. It is impossible 
here to give sufficient figures to deal adequately with this 
question, and those interested are referred to more 
extensive works.^ 

Much research has been done on the causation of the 
summer diarrhoea of infants. The disease attacks chil- 
dren primarily between the ages of a few months and 
two years. Often of rapid onset, death may supervene 
in severe cases within 24 hours ; even where the disease 
is not present in a severe form there usually follows a 
period of marked ill-health and lack of progress which 
may extend into many months, or, the child, being 
already debilitated, falls an easy victim to some re- 
latively mild inter-current complaint. 

Research has not shown that the disease is due to 
any specific organism, but it is almost certainly of 
infective origin, although there are predisposing causes, 
of which a high summer temperature is undoubtedly 
one of the most important. 

Reports from many medical officers of health of 
large towns in the north of England, with districts of 
insanitary condition, show that diarrhoea is especially 

Prevalent in these areas. Bad sanitation and bad 
ousing conditions are usually associated, but it would 
seem that the sanitation has the most bearing on the 
prevalence of diarrhoea. ^ 

* ReportH to the Local Qfjvemraent Board by the Medical Officer. 
Supplement to Annual Report for 1909-10, 1913-14, and 1915-16, 
and many reports by medical officers of health. 

' It ia impossible to describe the nauseatins; conditions in some 
of the towns where the sanitation is worflt. l^he houses are close 
together, emd almost M close to the dust-heap and pail-closets, or. 



Any one who has worked in insanitary areas in large 
towns in summer will need no figures to convince him 
of the risks run by infants in those districts. The 
figures (No. 7) in Dr. Robertson's Report on Birmingham 
Housing (Appendix VII) are very instructive. (Cf . his 
notes as to the sanitation on pp. 305 and 306.) ^ 

Artificially-fed infants suffer more severely from diar- 
rhoea than breast-fed infants, and an increase in breast- 
feeding will reduce the death-rate from diarrhoea. 
Recent figures relative to the feeding of infants are 
not available, but reference may be made to the same 
publications as those given above. In the Report for 
1912-13 (page 4) it was shown that the percentage 
of deaths due to diarrhceal diseases in the rural districts 
is much lower than for the towns in 1910, being 167 per 
cent, higher among children of 6-12 months of age 
in the towns than in the country districts. Groups 3 and 
4 can hardly be separated. The majority of deaths 
from measles and whooping-cough are due to the 
supervention of broncho-pneumonia, which proves 
fatal in a large number of cases. 

Respiratory diseases are infective in character, that 
is to say, they are caused by bacterial invasion. Such 
invasion will usually be most liable to occur in small, 
stuffy, dirty houses, where ventilation and cleanliness 
are difl&cult, or sometimes almost impossible. 

worse still, to the privy -midden. These are breeding-places for 
flies unless emptied at least once a week, which is rarely the case 
in the privy-midden districts. The flies swarm in the houses, on 
the walls, the food, the furniture, and settle on the children asleep. 
These germ -carriers pass irom the privy to the houses, and are 
potent agents for the spread of disease. In some districts a smell 
which defies description pervades the air, and enters the houses 
nearest to the privy. The wonder is that any one survives, not 
that young children die. 

^ Further evidence can be obtained by reference to the Report 
by the Medical Officer to the Local Government Board. 
Supplement to Report for 1912-13 and 1913-14, on the conditions 
in certain towns of Lancashire and on deaths from ages 0-5, pub- 
lished in 1915-16. 


The death-rates from these causes are ordinarily 
highest in the towns where housing and sanitation are 
unsatisfactory. Further, the rates vary in different parts 
of the same town. In the residential areas where there is 
plenty of air, and housing is good, the rates from these 
causes are low, and they rise rapidly as the quality 
of accommodation falls and the congestion increases. 
Overcrowding increases the Uability of infection. 

The high death-rate from Groups 2, 3 and 4 (p. 180) 
persists after the first year of age. It is shown in a Report 
of the Medical Officer to the Local Government Board ^ 
that about four-fifths of all deaths in the age period 1-2 
years may be attributed to infective diseases of various 

Bad housing and bad sanitation do not only affect 
children. No more powerful argument as to the effect 
on the population generally can be found than Dr. 
Robertson's Report above referred to, and published in 
the Appendix. (See Appendix VII.) 

Intensive work for child welfare has been carried on 
in the worst wards of Birmingham for a number of years, 
and although improvement has been effected, the work 
is clearly relatively powerless against the effects of bad 
housing and insanitary conditions. 

Child welfare work as ordinarily understood, and as 
dealt with in this book, has effected great improvement 
in the health of surviving children, and has reduced 
the infant mortality rate where this was not primarily 
due to impossible housing and sanitary conditions. 
Against these, more drastic measures are required, and 
the present campaign for improved housing and sani- 
tation, costly though it may prove, will be worth all 
and more than all that is spent upon it, for the health 
of the inhabitants will improve, and this should appreci- 
ably reduce public expenditure in other direct! ns. 

* Rop<jrt on Mortality ot ages 1-0, SuiJplemeiit to Annual 
Report, 1016-16, pp. 13 and U. 


Other causes of infant mortality have been much 
discussed, but their importance in producing a high 
infant death-rate cannot be regarded as established. 

The employment of married women is one of these 
subjects. Various works have been produced giving 
evidence on the desirability or otherwise of the employ- 
ment of married women .^ Apart from any special in- 
vestigation, it must be obvious that, as pregnancy is a 
physiological process and not a pathological one, some 
amount of work during this period need not afEect 
the health of the mother. Contrariwise, since an 
additional strain is placed on the body as a whole 
by the fact of pregnancy, there is less margin of 
energy for heavy work. Again, while there are young 
children at home, especially under school age, the 
absence from home of the mother must affect their 
health prejudicially. The argument that the 
mother's earnings so far improve the home con- 
ditions that her absence is of more value than her 
presence, only furnishes a forcible indictment of our 
economic arrangements. As a nation, we flatter our- 
selves that we value home life. Now some one must 
make a home, for homes do not make themselves, and 
the home for young children, at any rate, must be 
made by either the father or the mother, or both. Few 
people would deny that the mother must take the greater 
part of this work, and, in face of this admission, the 
work of the mother with young children is admittedly 
needed at home. 

Then ignorance and carelessness have been stated to 
be causes of child mortality. But the ignorance and 
carelessness are surely mainly due to the impossible 

* C5f. Report on the Work of Married Women, published by the 
Women's Industrial Council, and the Reports of the Medical 
OflBcer to the Local Government Board, 1909-10, p. 56 et sej., and 
the report on Lancashire, 1913-14 (p. 19), and on Child Mortality, 
1915-16 (pp. 73 et seq.). 


conditions under which so many of these poor mothers 
have to live. Who would not become careless in the 
insanitary conditions in which they are set, and from 
which they cannot move because there is not another 
home to move to even if better accommodation can be 
afiorded ? 

If the better-to-do classes of this country had any real 
appreciation of the conditions under which many of their 

Eoorer neighbours live, the housing campaign would 
ave been unnecessary. It is the ignorance of the 
well-to-do which causes infant deaths, far more than 
that of the poor mothers themselves. Ignorant 
the latter may be, but nearly all are teachable. 
It is hard to be taught unless reasonable facilities for 
subsequent practice are available. 

Maternal Mortality. — The deaths among women 
due to childbirth have been investigated for many 
years, and a comprehensive statistical investigation 
was carried out by Sir Arthur Newsholme in 1915.^ 
It is very generally admitted that many of these deaths 
are preventable. But at present it would be difficult 
to say that the lines of work which would be most 
efEective are well known. Certainly a considerable 
number of deaths are due to infection and puerperal 
fever after childbirth, and it is commonly stated that 
this is due to some carelessness on the part of either 
doctor or midwife. This is doubtless a common source 
of trouble, but cases arise when it appears that auto- 
infection occurs. The point is still sufficiently indeter- 
minate to provoke animated discussion at medical 

Even less information is available as to the other 
causes producing death, although certain of these are 
emerging into the light. When an adequate maternity 
service is established, the work carried out, especially 
in the wards and laboratories, which will, of course, 
* B«port on Maternal Mortnlity, already oiled. 


form part of the service, should show the lines along 
which prevention can best be secured. 

The causes of infant mortality only emerged gradually 
in the course of work, and the same will no doubt be true 
of those causes which are responsible for maternal 

^ Supplement to the Report of the Medical OflScer to the Local 
Government Board 1914-15, and numerous papers in medical 
publications, of which the most recent is one by Mr. Bonney {Proc. 
Boy. Soc. Med., June 1919) given at the Gynsecological Section of the 
Royal Society of Medicine. The interesting discxission which was 
provoked should also be read. 


Notifiable Diseases in Relation to Maternity and 
Child Welfare, with Notes on Measles and 

The diseases which occur most frequently among 
children after infancy and among adults are not so 
prevalent among children of tender age. Thus the total 
number of deaths from notifiable diseases (such as scarlet 
fever, diphtheria, etc.) among infants under one year 
is almost negligible, while the deaths from measles and 
whooping-cough amount to a considerable figure. 
(Cf. p. 180.) Of the common infectious diseases these 
last two alone will be considered here. 

In 1915 measles and German measles were made 
notifiable diseases, and a considerable amount of work 
was inaugurated under the Local Government Board's 
Order. The experience gained showed that, while 
the work undertaken was of great value, notification 
under the ordinary procedure could be dispensed with, 
and the Order was recently rescinded, as from 31st 
December 1919. Whooping-cough is fully as trouble- 
some and dangerous a disease as measles, and there is no 
intrinsic reason why the one should have been made 
notifiable rather than the other. The outbreaks of 
measles which occurred in camps during the early part 
of the war drew special attention to the disease, and it 
was made notifiable while whooping-cough was not. 

Both these diseases are not in themselves necessarily 
dangerous. Both, however, primarily attack the upper 
pait of the respiratory passages, and both may, therefore, 


easily pass by extension to the bronchi and lungs. 
Measles, as is well known, starts with a running of the 
eyes and nose, and whooping-cough with an irritating 
cough. Further, apart from the complications of 
bronchitis or of broncho-pneumonia (which last is 
fatal in a high percentage of those suffering from it) 
there are after effects which may arise from the mildest 
attack, and which may lead to a fatal result. A great 
many children have a comparatively slight attack, 
but remain listless, pale, without appetite, and so forth. 
These children are fruitful soil for the tubercle bacillus, 
which takes its victims in considerable numbers from 
among them. By the time the case is diagnosed as 
tubercle, the mother has probably forgotten about 
the attack of measles or whooping-cough, and, even if 
asked about previous ailments, sees no connection 
between the two. Measles, perhaps even more than 
whooping-cough, is often looked upon as a mild trouble 
which requires no attention. Many cases are mild, but 
all are liable to the dangerous complications caused by 
the extension of the disease from the naso-pharynx 
to the bronchial tubes and then to the lungs. Also 
a discharge from the ear, which is symptomatic of an 
unsatisfactory condition, frequently gives rise to trouble 
after these diseases have passed off. 

The Local Government Board enjoined that all cases 
of measles should be visited, with the object of calling 
the parents' attention to the importance of care, to the 
advisabihty of calling in the doctor, and in addition to 
afford opportunity of tracing other cases. Also, the 
visitor was to give advice on general lines. 

The provision of nursing aid by local authorities for 
those in very poor surroundings was allowed under the 
Public Health Act of 1875, which gave power to local 
authorities, subject to the consent of the Local Govern- 
ment Board, to provide nursing for epidemic diseases 
among the poorer classes. 


A great many local authorities have adopted 
measures in accordance with the recommendations of the 
Local Government Board. No general survey of stat- 
istics has been pubhshed, but many medical ofl&cers of 
health have expressed their belief in the great value of 
the aid provided, which they consider has saved the Uves 
of many children. 

In the memorandum issued by the Local Government 
Board on the subject of measles and its notification, 
the Medical Officer to the Board says : " In the 
three years ] 911-13, 33,457 deaths were caused at 
ages under five by measles, and at the same ages 83,650 
by bronchitis and pneumonia, which, in many instances, 
are the terminal stages of an attack of measles (or 
whooping-cough) which is not mentioned in the death 

Other notifiable diseases are removed to hospitals, un- 
less there is adequate means of isolation and disinfection 
at home, but measles is not taken into the fever hospitals, 
unless the case is especially bad. Cases of whooping- 
cough are, if anything, in a worse plight. In many ways 
a more troublesome but equally dangerous disease than 
measles, no provision whatever is made for it. A few 
cases with broncho-pneumonia are received into 
hospitals, but the number of beds available is almost 
negUgible as compared with the need. 

It 13 not sufficient that the child should be visited 
during the attack. Visits must be continued until the 
child has completely recovered, and, whenever possible, 
it should be examined medically to make sure that there 
is a satisfactory return to health. The child welfare 
centre can properly assist in such work. 

Actual nursing should not ordiucarily be undertaken by 
the visitor. This should be arranged for through a 
district nursing association, or in connection with 
infectious diseases hospitals. 

The circular issued by the Ministry of Health in 


connection with the rescission of the Notification of 
Measles Order, impresses on local authorities the im- 
portance of providing means for sending children to 
convalescent homes when recovery is not proceeding 
satisfactorily. The circular, which contains much 
further information of interest, is reprinted in Appendix 

Two diseases affecting maternity work are notifiable — 
puerperal fever and ophthalmia neonatorum. 

The notifications of the former, puerperal fever, are 
not accurate, the number of deaths from this cause 
being, in some districts, in excess of the notified cases. 
Midwives must notify cases of any suspected infection 
occurring in their practice to the local supervising 
authority, and must send for medical aid. The notifi- 
cation to the medical officer of health is made by the 
doctor. There is considerable divergence of opinion 
as to the definition of puerperal fever, and this leads 
to a good deal of unavoidable inaccuracy in notifica- 

The occurrence of a case in the practice of a doctor or 
midwife is held to be a sign of lack of care or of proper 
methods, and this leads to disinchnation to notify on 
the part of the doctor. As already mentioned, although 
no doubt many cases could be avoided with greater care, 
the trouble does arise even where the greatest care has 
been taken. The deaths from puerperal fever are shown 
in the Reports of the Registrar-General. 

Ophthalmia neonatorum has been notifiable for some 
years. It consists of an inflammatory condition of the 
eyes which, in bad cases, may spread to the eyeball, 
and cause partial or complete loss of eyesight. The in- 
flammation is due to infection by micro-organisms which 
has taken place during the passage of the infant through 
the vagina of the mother. Infection may also take 
place from some cause or another after birth. There are 
several organisms which produce this condition, but 


the one most to be feared is the gonococcus, the cause 
of one of the venereal diseases. 

The careful washing of the eyes with a bland lotion 
immediately after birth, if carefully carried out, will 
prevent inflammation in the majority of cases. The 
trouble develops in the first few days after birth, and, 
if treated at once, can usually be cured. If left alone, 
it may easily lead to bhndness. Midwives are required 
to notify all cases occurring in their practice both to 
their local supervising authority and to the local 
sanitary authority, unless the latter has been notified 
by the doctor. When the inflammation appears the 
midwife should send for medical advice at once. (Cf. 
p. 132.) 

Of recent years much has been said about the effect 
of venereal diseases on infant welfare. The two 
venereal diseases concerned are syphilis and gonor- 

Syphilis undoubtedly is a cause of still-births, and of 
other troubles occurring in the children of syphilitic 
parents. But the statistics on this subject are incom- 
plete and unreliable. There is no real evidence to show 
that the alarming suggestions and even statements 
often made on this subject are justified. (Cf. p. 145.) 

The work of Fildes,^ carried out on 1015 women in the 
East End of London, showed that in these cases evidence 
of syphilis was found only in 14 mothers, and of the 
childien of these, only 4 showed definite signs of the 
disease. Unfortunately 6 siipected children were 
lost Bight of. But the 8 investigated later were out of 
677 cases, giving a percentage of 0-59, which is hardly an 
ala ming one. Against F. Ides' work it has been urged 
that the majority of the women were Jewesses, and that 
it is well Imown that Jews have a lower percentage 
incidence of venereal disease than English people. No 
figuies appear to be available which prove this assertion 
* Report to the Local Government Board (Now Serios), 106, 1916. 


which is illustrative of the absence of reliable evidence 
upon the subject. For further details, the publications 
of the Eugenics Education Society may be consulted ; 
also the Eeport of the Koyal Commission on Venereal 
Disease, etc. 

Notification of Summer Diarrhoea. — A few districts 
have asked for and obtained power to make this disorder 
notifiable, either at all times or during certain months 
of the summer. The trouble usually arises as soon as 
the weather becomes and remains hot. It has been 
found that when there is one bad case in the family, 
there are usually other cases as well which pass almost 
unnoticed as compared with the severe case. It is very 
important that attacks of diarrhoea should receive im- 
mediate medical attention, and in-patient care may be 
necessary. The health visitor should be always looking 
out for these cases during the summer-time and should 
advise the prompt withdrawal of milk from artificially- 
fed children, the giving of plenty of water, and medical 
advice at the earliest moment. In a very hot summer 
the disease may become epidemic in character, and great 
difl&culty may be experienced in dealing with the cases. 
In such circumstances it may be desirable for the child 
welfare centres to undertake treatment of diarrhoea 
cases at special hours, but the infant affected by diar- 
rhoea should not mix with the healthy infants. Inas- 
much as the notification is made by the doctor, it is evi- 
dently not made until medical advice has been obtained. 
As this will usually mean that the child is really ill, the 
value of the notification is somewhat doubtful, as the 
cases are not seen in the early stages. In a few areas 
special beds are available for diarrhoea cases during the 
summer, but such cases should not be nursed in the same 
ward with othe.- diseases. 



Local Government Areas 

It is hardly possible for the student of child welfare 
work to have an intelligent understanding of the whole 
position, without at least an elementary knowledge of 
local government, as it is carried out in this country. 

The study of English local government provides 
much that is in the highest degree interesting. Un- 
fortunately for the student, there appears to be no 
concise general text-book on the subject. Most of the 
available books are either too elaborate for students, or 
partake of the nature of pr mers, and do not deal with 
some of those aspects which are essential for the student 
of child welfare work. 

An attempt is made in these chapters to give some idea 
of local authorities and local government in relation 
to child welfare work generally. The public health 
work of local authorities at the present time ncludes 
child welfare work, and this latter cannot be considered 
apart from the general machinery of public health 

The whole country is divided up into separate areas for 
the purpose of public health work, and every inhabitant 
figures under one and sometimes two local authorities. 
Each geographical county learnt in the schoolroom is 
divided in the area known as the county, while certain 
of the large towns are known as county boroughs. 
The " county ** of local government is the geographical 
county with certain large towns taken out of it. The 



geograpliical county thus reduced is known as the 
" administrative county " because it forms the unit 
county for pu'poses of government. Each county 
borough is a separate unit of local government. 

There are more administrative county areas than 
geographical counties, because some of the large counties 
are subdivided for the sake of convenience, and a few of 
the smaller counties have been split for reasons which 
are probably good even if obscure. 
' Thus, Yorfehire is divided into three " Ridings," 
West, North and East ; Lincolnshire has three " parts," 
Holland, Kesteven and Lindsey ; Suffolk and Sussex 
are each divided into " East " and ** West " ; the Isle of 
Wight has been separated from Hampshire ; the north 
part of Cambridgeshire is termed the Isle of Ely, and 
the north of Northamptonshire the Soke of Peter- 
borough ; each of these having independent admini- 

Apart from these exceptions, the administrative 
counties coincide, with a few unimportant exceptions, 
with the boundaries of the geographical counties with 
the county boroughs taken away. Each county has 
within it other administrative areas of different types, 
many of them having been established before the ad- 
ministrative county was defined, and having varying 
degrees of independence in regard to their own local 

Thus, each county has within its boundaries municipal 
boroughs, many of which are towns of considerable age, 
having received charters of incorporation in times 
remote from our own. Certain of the older boroughs 
have ceased to exist for various reasons, and many of 
the present boroughs are not towns of any degree of 
antiquity. Charters are still given at the present time. 
Besides the boroughs, there are urban and rural districts ; 
the whole country being completely subdivided into 
these areas. Some counties have a large number of 


boroughs, others very few, and the number of urban and 
rural areas depends largely upon the population. 

The simplest unit within the county is the rural 
district, and the next in the scale of importance is the 
urban district, and then the borough. Each of these 
units is theoretically subdivided into parishes, but 
as the parish councils or parish meetings take no 
share in child welfare, they will not be considered 

London forms a county, and is subdivided into twenty- 
eight Metropolitan boroughs and the City of London. 
Each unit mentioned above possesses certain differences 
in regard to self-government. The powers of urban 
and rural districts differ in a few particulars. A 
populous part of a rural area will, however, usually 
wish to become an urban district, since it then becomes 
independent of the less populous part of the rural 
district, and acquires autonomy in regard to sanitation 
and other matters. The boroughs have certain powers 
and principles not possessed by an urban district, 
while certain powers for the whole area are in the 
hands of the county council. 

These powers have been conferred at different times 
by Act of Parliament. Every Act passed by Parlia- 
ment must either be carried out by the Government 
direct, or by some local body. Each area of local 
government has an elected council which is responsible 
for the carrying out of the duties laid upon it by Parlia- 
ment, and it is this council which forms the local 
authority for the area. 

From time to time, as Acts are passed, further duties 
are laid upon the various local authorities. Formerly 
there was a tendency to place the powers and duties 
in the hands of the smaller units. The counties and 
their councils, as at present established, are of more 
recent development than the other areas, and it was 
therefore inevitable that the duties should be laid upon 


the existing units. Latterly, however, there has been 
an increasing tendency to increase the powers and duties 
of the county councils, rather than those of the smaller 

Before considering this point in detail some attention 
must be devoted to the county boroughs. It has 
already been explained that these are, as it were, carved 
out of the geographical county, and are independent of 
it. There are 82 county boroughs in England and 
Wales. A county borough must have a population 
of not less than 50,000, or there must be some other 
special circumstances. County boroughs were set 
up under the Local Government Act of 1888, and 
a few old cathedral cities with populations well below 
50,000 were allowed to become county boroughs. 
Since that date all except three of these cities, 
namely, Canterbury, Chester, and Worcester, have 
reached the required figure. The county borough is 
an independent unit of local government, and if the 
duties and powers conferred upon these bodies are to be 
efl&ciently carried out, a large population is necessary. 
Many people consider that the population limit of 
50,000 IS too low. 

Every town of 50,000 inhabitants does not, however, 
automatically become a county borough, although it 
is usually the final ambition of every district of this 

The Registrar-General in dealing with the figures of 
birth, deaths, etc., disregards the administrative dis- 
tinction, and classes all towns with populations of over 
50,000 as " large towns," and all towns having popula- 
tions of between 20,000 and 50,000 as " smaller towns." 
But this classification does not apply to administrative 

Suppose, for example, that a part of a rural district 
becomes very populous, that part which has the largest 
population may wish to become independent of the 


rest of the area. It may then make application to 
become an m^ban district, and to be taken away from 
the rule of the rm"al district in which it is situated. 
The would-be independent district must apply to the 
county council concerned. If the county council 
approves, an Order is made creating the urban district. 
This Order must be confirmed by the central Govern- 
ment department concerned — ^forming the Local Grovern- 
ment Board — now the Ministry of Health. 

Again, if the whole of a rural district becomes populous, 
it may be divided into several urban districts, e.g. 
Croydon rural district was, in 1916, broken up into three 
urban districts, namely, Coulsden and Purley, 
Mitcham and Beddington, and Wallington. 

Rural districts situated near large towns may, how- 
ever, have another fate. The town may cast envious 
eyes at the still available open spaces, and may succeed 
in getting its own boundary enlarged so as to enclose 
some part of the adjacent rural district. 

Urban districts usually desire to become boroughs, 
and begin to consider the question as soon as they feel 
sufficiently important. The acquisition of powers and 
duties nearly always carries with them increased expendi- 
ture. Sometimes, therefore, economy prevails, and a 
large urban district may refrain from asking for further 
powers. On the other hand, in the neighbourhood of 
London, there are a number of very large and populous 
urban districts which are most anxious to obtain further 
powers but whose demands have so far been continu- 
ously frustrated by the large bodies in their vicinity. 
Many of these districts have populations of over 100,000, 
and find their lack of independence very iiksome. The 
further powers sought for can be obtained either by a 
Provisional Order made by the Ministry of Health, and 
subsequently confirmed by Parliament, or by a direct 
application to Parliament. 

Boroughs usually want to become county boroughs 


as soon as their population admit of this. In this de- 
mand, however, they may meet with strenuous opposi- 
tion from the county from whose jusrisdiction they 
wish to free themselves. The more populous the county 
the less opposition is usually raised, but in the small 
counties the independence of a large borough would 
seriously affect the financial position of the county. 
For instance, just before the war Luton and Cambridge 
applied to Parliament to become county boroughs. 
After much fighting, the Bill was passed by the Commons 
and thrown out by the Lords, owing to the pressure 
brought to bear in that House by the county councils 
concerned. These towns are the largest towns in 
Cambridgeshire and Bedfordshire respectively, and they 
pay large contributions to the county rates. As these 
applications are often very costly to promote, a borough 
will not make an unnecessary apphcation to become a 
county borough unless there is a reasonable chance of 
success. The limit of ambition has, however, not been 
reached when a borough has obtained independence and 
become a county borough. There are still fresh fields 
of enterprise awaiting it. The larger the town the more 
does it cast envious eyes on the small districts around 
it, and wish to include them in its boundary. Thus, in 
1912, Birmingham incorporated into its territories 
several large areas, namely, Handsworth, having a pop- 
ulation of 09,000, Aston Manor, with 75,000 inhabitants, 
and King's Norton, Northfield, with 82,000, together 
with two rural areas of smaller populations. At 
the present time several large towns are promoting 
schemes for including a number of adjacent areas 
with very large populations, among them are Leeds, 
Sheffield, Halifax, Nottingham. 

In these cases, although the districts lose their auto- 
nomy, they usually stand to gain in other ways by being 
incorporated with a large town. 

Again, several large adjacent districts may decide to 


combine in order to form one powerful unit instead of 
several small units. The present county borough of 
Stoke-on-Trent was formed in 1912 by the union of six 
other districts, of which five form the " Five Towns " of 
immortal fame owing to the works of Arnold Bennett. 
Other examples could be given. 

It is thus shown that while the whole county is divided 
into areas of different classes for the purpose of local 
government, these areas may change their nature and 
their boundaries from time to time. The local govern- 
ment areas for each coimty can be shown in diagram 
as follows : 

Geographical County 

Administrative County County Boroughs (the number 

I varying in each county) 

Boroughs Urban Districts Rural Districts 

and in London 

London County 

I I 

City of London 28 Metropolitan Boroughs 

All the above areas, except counties, are often termed 
"Sanitary Authorities," because to them has been 
entrusted the carrying out of the Public Health Acts. 
At the time of the passing of the PubUc Health Acts the 
counties were in a less defined position than at present, 
and the duties were therefore laid on the existing 
smaller local authorities. Coimty councils are there- 
fore not local sanitary authorities although they are 
local authorities. The same remark applies to the 
Metropolitan area. The London County Council is 
not a sanitary authority wilJunthe ordinary meaning of 


the term, but its constituent boroughs and the City 
have these powers. 

Poor Law. — The whole country is also divided into 
Poor Law areas, which do not by any means always 
coincide with the boundaries of the local government 
areas. The smallest unit is a " parish," and the 
parishes are aggregated into " unions." So far as pos- 
sible the boundaries of unions are made coterminous 
with those of county areas, even though there may be 
several unions in the one county. 

The Poor Law is hardly concerned with the child 
welfare movement as ordinarily understood, although 
there is abundant opportunity for child welfare work 
among children under the care of the Poor Law. It is 
not necessary for the present purpose to consider the 
Poor Law areas any further, although some reference 
to the machinery under the Poor Law will be necessary 
in connection with certain aspects of finance. 


Local Government Authorities : their Powers 
AND Duties 

The various types of Local Government areas which 
have been described in the preceding chapter do not 
possess similar powers, and they have difEerent duties to 
carry out towards those living within their boundaries. 
A mere enumeration of the duties and powers which 
have been placed by Parliament in the hands of these 
authorities would not alone prove very enlightening, 
because it would provide no explanation as to the reason 
why certain authorities should be called upon to under- 
take certain functions. The only way to obtain an 
intelligent knowledge of the elementary principles 
which have governed the allotment of duties and 
powers, is to consider the development of the Local 
Government areas with regard to the political position 
at the time the duties were laid upon the authorities 
concerned. It will clearly be impossible to give more 
than a few brief sentences of explanation in a work 
such as this. 

Certain functions of Local Government were being 
undertaken in this country for hundreds of years before 
any question of Public Health administration was even 
considered. The history of England is full of the 
continuous controversies between the king and the 
people for the possession of power. The tendency of 
the nation has hitherto been to demand more and more 
powers of local self-government, that is, to have powers 


of Local Government as distinct from central govern- 

The first stage was that connected with the sup- 
pression of crime and the maintenance of the public 
peace. Justices of the Peace were appointed from 
among the landowners of the district in the time of 
Edward III. in place of the sheriffs. The Justices 
were appointed by the Crown, and were given powers 
to deal with local matters of justice, working side by 
side with the itinerant judges who, had been established 
under Magna Charta. In addition, the Justices were 
responsible for the control of the police, and at subse- 
quent dates the administration of the Poor Law, licensing, 
and the care of the Highways were placed in their hands. 
They thus came to exercise great powers in their own 
districts, and, being appointed by the Crown and not 
subject to election, they were relatively independent 
of control. A good deal of abuse of position crept in 
and it became necessary to curtail their powers and 
functions. This was accomplished after much con- 
tention at later periods. 

The areas of local administration very early became 
divided into towns and counties. Many of the towns 
obtained charters which exempted them from the 
control of the county, and allowed them to control their 
own affairs subject to Parliament. They had their 
own Justices of the Peace, and certain of the inhabit- 
ants, burgesses, were responsible for the internal 
affairs so far as any arrangements existed at the 

The Elizabethan Poor Law required the inhabitants 
of a district to be charged with the cost of maintaining 
their own poor, and the money raised for this purpose 
was known as the poor-rate, and forms the beginning 
of local taxation in this country. Before the dis- 
solution of the monasteries, the relief of the poor had 
been carried out by religious bodies. The Elizabethan 


Poor Laws placed tlie duty upon the locality concerned. 
The ecclesiastical parish was taken as the unit of Local 
Government, and each parish was required to have an 
overseer, who should levy the money required in the 
form of a rate on the inhabitants. These overseers 
worked under the already existing Justices of the 
Peace, and were appointed by the said Justices. 

Later in the reign of Elizabeth the provision and 
maintenance of roads was also placed in the hands of 
the Justices, and it was clearly convenient that the 
money required should be levied by the overseers 
who levied the poor-rate. Other money required for 
expenditure thus came to be levied with the poor-rate, 
and the practice holds at the present day. 

The method of government by burgesses, as found 
in the towns, gradually became unsatisfactory, owing 
to the fact that, as time went on, the burgesses became 
less and less representative of the people, and often 
did not even live in the town. So great was the dis- 
satisfaction among the people of the towns as a whole 
that, whenever any new duty had to be carried out, 
it was common to form a separate body of persons 
for the purpose. These bodies were known as " Local 
Boards " or " Commissioners " or " Trustees," and 
they grew up in different localities for difierent purposes, 
and with different powers. There was little imiformity 
of administration or of powers among the various 
towns throughout the country. 

In 1835 the Municipal Corporations Act was passed 
by Parliament, after much debate, under which Municipal 
Government was reorganised. The Act , forms the 
basis of much of the municipal life of the present day. 
Under this Act a Council was to be formed in each 
town, the members of which were to be elected by the 
ratepayers who had lived in the town for not less than 
three years. The Council was made responsible for 
the administration of local revenues and finance, and 


for certain of the duties hitherto carried out by the 
Justices of the Peace. These last, however, retained 
the control of the police and of licensing, together with 
theif judicial functions. Certain differences in these 
respects were arranged as between different classes 
of boroughs, but only the broad fact of the division 
of function in the towns is now under consideration. 

The Act further provided for the election of alder- 
men as well as councillors, and for other matters regard- 
ing the carrying out of the decisions of the Council. 
The towns considered eligible for the powers conferred 
by the Act were set out in the schedule of the Act, 
power being given for subsequent additions to the 
number as, and when, this might be approved by 
Parliament. Commissioners appointed after the pass- 
ing of the Act dealt with the boundaries of the towns 
concerned, and also with the advisability of dividing 
the town into smaller areas or wards for purposes of 
the election of councillors. The number of councillors 
to be elected was also fixed. 

The powers possessed by the local boards already 
referred to were not compulsorily transferred to the 
Council, but provision was made for their transference 
if 60 desired. The boards had been concerned with 
matters such as lighting, cleansing, paving, etc., 
their functions differing in the various towns. 

Under the Act some 170 boroughs were created, and 
these were required to reorganise their internal affairs 
to bring them into conformity with the provisions of 
the Act. During the years following the passing of the 
Act, all but a few towns did, in fact, transfer the powers 
exercised by the various local boards to the hands of the 
Town Council. The changes arising under the Act of 
1835 played an important part in the development of 
Local Government as we have it at the present 

It will be simplest to follow the fortunes of the 


boroughs a little further before returning to a con- 
sideration of the development of Local Government in 
the county districts. 

The Pubhc Health Act of 1848 formed the beginning 
of Public Health legislation in this country. Under it 
a Central Board of Health was formed with certain 
powers to secure improvements in local matters. Gener- 
ally, it was intended to deal with the water supply, 
drainage, sewerage, cleansing, paving, and other sanitary 
questions. Boroughs could adopt the Act and become 
Local Sanitary Authorities. In other districts where 
it was desired to adopt the Act, a special Local Board of 
Health was set up. The Pubhc Health Act of 1858 
developed further the powers of the local bodies. 

The Local Boards of Health also became the surveyors 
of highways for their own districts, and took over the 
powers originally assigned to the bodies deahng with 
the highways. Parishes having populations of 3000 
or over, were allowed to become Urban Sanitary 
Authorities, to elect their own Board of Health, and 
to control their own highways. 

The later Pubhc Health Acts of 1872 and 1875 further 
enlarged and consohdated the boroughs and urban 
sanitary districts as Local Sanitary Authorities to carry 
out the duties and powers conferred under those Acts. 
In 1888 certain of the boroughs became county boroughs, 
and further freedom was allowed them in the exercise 
of Local Government. As already explained, county 
boroughs must have a population of not less than 
50,000 inhabitants, except in the case of a few ancient 
cities whose population did not reach this amount. 
It should also be borne in mind that districts with 
50,000 of a population do not automaticallybeco me county 
boroughs, but mast be empowered by Parliament to 
receive this dignity. Since 1888 many duties and 
powers have been added to those conferred under the 
Fubiic Health Acts, and this will be dealt with after 


the county areas have been considered somewhat 

The Elizabethan Poor Law applied in the county- 
areas just as in the towns, and its administration was 
placed in the hands of the Justices of the Peace, as were 
also the other duties and powers already mentioned 
in connection with the development of Urban Govern- 
ment. The abuses already referred to arose in similar 
manner in the counties, and led to a demand for re- 
organisation, and to a determination that no further 
powers should be placed in the hands of the Justices. 
The Poor Law of 1832 provided for the formation of 
" unions " of parishes for the administration of the 
Poor Law. The care of the highways had originally 
been placed in the hands of the parishes, but the areas 
were too small, and in many cases too sparsely populated 
and hence too poor, to be able to carry out their duties 
with efl&ciency. Under the Highways Acts of the 
middle of the last century, Highways Boards were 
formed with larger areas of administration. The 
Public Health Acts of 1872 and 1875 parcelled the whole 
country into local sanitary areas, and the unions 
formed the basis for the rural sanitary districts, so far 
as this was geographically practicable. Thus, the 
whole geographical county was divided into urban 
and rural sanitary districts, boroughs, and county 
boroughs. Gradually, and after much persistence, the 
Highways Boards were merged in the rural sanitary areas, 
and the last of them were finally swept away by the 
Local Government Act of 1894, when their powers were 
definitely transferred to the Rural District Councils. 

The county of former days still existed, but the county 
boroughs were taken out of it altogether. Until 1888 
its powers were primarily connected as heretofore with 
the administration of justice, and with those other duties 
which had from time to time been laid on the Justices 
of the Peace. In 1888 when the county boroughs were 


taken out of the county, a reorganisation of tlie work 
was undertaken, and County Councils were set up for 
each administrative county, and certain of the duties 
of the Justices of the Peace were transferred to them. 
The Councils were to be elected on somewhat similar 
lines to the Councils of the other areas, and it was pro- 
posed at the time that these bodies should provide a 
means for the decentrahsation of power. 

Certain financial arrangements accompanied the Act 
of 1888 in respect of the readjustment of duties as 
between the Justices and the counties and county 
boroughs, the net result of which was the payment of 
a grant by the Exchequer towards the cost of the 
administration of the counties and county boroughs, 
certain specified items to have precedence in the alloca- 
tion of the grant. 

Provision was also made for the levying of a coimty 
rate over the whole area of the administrative county 
for certain purposes common to the whole area, such 
as the repair of main roads, the cost of the poUce, etc. 
It should be noted that no sanitary powers under the 
PubUc Health Acts are conferred on the County Councils 
who are not Sanitary Authorities. 

The Parish Councils Act of 1894 provided for the 
establishment of Parish " Councils " or of " Meetings " 
in the case of very small populations, and certain minor 
powers were conferred on these bodies connected with 
footpaths, burial-grounds, lighting, etc. Many parishes, 
however, have not taken advantage of the opportunity 
of self-government thus offered to them. 

The Notification of Infectious Diseases Acts of 1889 
and 1899 placed the control of infectious diseases in 
the hands of the Sanitary Authorities, both urban and 
rural. This should involve the provision of hospital 
accommodation for such cases. It may be said in 
passing that the sanitary areas are in many cases too 
small to be able satisfactorily to carry out the duties 


imposed upon them, and that the county, county 
boroughs, and larger boroughs would, in the majority 
of cases, be the better units for the purpose. 

Li 1902 the Education Act and the Mid wives Act 
placed further powers on Local Authorities. The 
Education Act provided for the formation of Education 
Committees, which should be responsible for the work 
under the Act, under the Councils of the various 
authorities. Those authorities were County Councils, 
County Borough Councils, boroughs having a popula- 
tion of 10,000 or over at the time of the passing of the 
Act, and urban districts having a population of 20,000 
at the same date. 

The medical inspection of school children was made a 
duty of the Local Education Authority by the Educa- 
tion Act of 1907, and the duty of arranging treatment 
for school children has been laid upon them by the 
Act of 1918. 

The Midwives Act of 1902 placed the inspection of 
midwives in the hands of the counties and county 
boroughs, the counties having power to delegate their 
powers of inspection to the smaller districts if they so 
wished. At first, such delegation was widely practised, 
but later it was found to be unsatisfactory, and the 
Midwives Act of 1918 rescinded the permission. 

In 1907 the first Notification of Births Act was 
passed, being adoptive in character. This has already 
been dealt with sufiiciently fully, and it need only be 
again mentioned that the Act might be adopted by any 
of the authorities, either Sanitary or County. The 
Local Government Board, however, did not at fiist 
favour its adoption by the counties. 

In 1909 the Housing and Town Planning Act gave 
considerable impetus to housing improvements. Prior 
to this date there had been Acts for the improve- 
ment of the Housing of the Working-Classes and the 
powers and duties had been laid on the Local Sanitary 



Authorities and not on the counties. The Housing 
Act of 1919 lays the duties upon Sanitary Authorities, 
except in particular cases. Later Acts for Maternity 
and Child Welfare, namely, the Notification of Births 
(Extension) Act of 1915, and the Maternity and Child 
Welfare Act of 1918, placed the powers in the hands of 
the same authorities as the Notification of Births Act 
of 1907. But experience had shown that the Acts 
could be better and more economically worked by the 
larger authorities, and the tendency now is to eliminate 
the small authorities, and to allow only the county 
boroughs, the counties, and the large boroughs and urban 
districts to undertake independent schemes for child 

Then, again, in 1911, in connection with the National 
Health Insurance Act, the county boroughs and counties 
were the authorities selected for carrying out the tuber- 
culosis work inaugurated under the Act. The working 
of the Mental Deficiency Act (unfortunately postponed 
in application by the intervention of the war) was also 
placed upon the counties and county boroughs. 

Since the formation of the County Councils on the 
present basis, most of the fresh duties have been laid 
upon them and upon the county boroughs, except those 
duties which appeared to be so closely allied to sanita- 
tion as to render it difficult for them to be discharged 
by any but a Sanitary Authority. Such a matter is 
housing, but it remains to be seen in the near future 
how far the smaller Local Authorities will be able and 
willing to respond to the demand now being made upon 
them for building houses. The problem of tuberculosis 
is closely bound up with housing conditions, and sanita- 
tion generally, as, indeed, is child welfare work. It is 
impossible to hope for satisfactory results unless there 
is close co-operation between both sets of authori- 
ties. This has already been referred to in connec- 
tion with the work of the health visitor in rural areas. 


It is not necessary here to enumerate all the other 
varied duties which have been laid upon the different 
Councils, but it may be of interest to give a summary 
of the main branches of work allotted to each. The 
arrangements in London are of a different nature, and 
are given separately. 

It will be simpler if the duties of the County Councils 
are given first, since these duties, as well as others, are 
all laid upon the county boroughs. 

Main duties of the County Councils : 

f Control of Police 

Not directly 
health matters 

Pertaining to 

Provision and care of main roads. 
Provision and maintenance of asylums. 
Educational work of all kinds, except 

in most boroughs and certain urban 

districts (this carries with it school 

medical work). 
Duties under the Small Holdings Act. 
/■Powers of action in default of smaller 

Work under the Rivers Pollution Act. 
Inspection of midwives. 
Care of tuberculous persons. 
Maternity and child welfare (except in 

some districts). 
Working of Mental Deficiency Act. 
Food and Drugs Act. 

County boroughs have all the powers and duties of 
County Councils, and others in addition. These addi- 
tional matters may be roughly classed under three 

Main Duties and Powers of County Boroughs : 
As for County Councils, and in addition — 

'Sewerage acid disposal and refuse collec- 
tion, removal, and disposal. 
Water supply. 
Sanitary powers J, Housing of the working-classes. 

^ P "I Infectious diseases prevention and pro- 

vision of hospitals for infectious diseases. 
Provision and charge of common lodging 


f Provision and care of burial-grounds. 
General I Pro^isio'i &^d care of public baths and 

' -| washhouses, 
I Provision and care of recreation grounds, 
I Provision and care of pubUo libraries. 

Remunerative . f Supply of gas. 

■( Supply of tramways. 
I Supply of electricity, etc. 

Of the above, the sanitary powers belong also to 
boroughs, urban and rural districts, whUe, as has 
already been explained, some boroughs and ■ urban 
districts have powers connected with police and educa- 
tion. The " general " powers may be placed on the 
Parish Councils or Meetings, subject to limitations as to 

In London the Metropolitan boroughs are Sanitary 
Authorities, but carry out certain only of the above 
sanitary powers. For example, water supply is in the 
hands of the Metropolitan Water Board, and the pre- 
vention of the pollution of rivers is in the hands of the 
Thames and Lea Conservancy Boards, while hospitals 
for infectious diseases are provided by the Metropolitan 
Asylums Board. 

Generally, on other matters the London County 
Council deal with those which relate ordinarily to 
more than one borough. Thus, it deals with certain 
housing schemes, and parks, and open spaces. It also 
undertakes some parts of the tuberculosis work (some 
of which is in the hands of Metropolitan boroughs), 
in addition to the other duties of a County Council . 

The inspection of mid wives is in the hands of the 
London County Council, but the work under the Noti- 
fication of Births and the Maternity and Child Welfare 
Act rasts with the boroughs. 

There is here no direct concern with the Poor Law, 
but in dealing with matters of Local Government 
it is necessary to mention it, because its working 
interlaces with that of other branches of Local Govern- 


ment, notably on the question of rates, and in connection 
with the election of members of councils. Also the 
work under the Vaccination Acts is carried out by the 
Poor Law officials, both the vaccination officer and the 
public vaccinator being appointed by the Poor Law 
Guardians of each Union. Vaccination was intro- 
duced at a time when the sanitary districts had not 
been established on their present basis, and it was 
found convenient to place the duties under the Acts 
in the hands of the guardians. Although the responsi- 
bility for dealing with all matters relating to infectious 
diseases is in the hands of the Sanitary Authority, in- 
cluding measures arising in connection with any case 
or cases of small-pox, routhie vaccination is still under 
the Poor Law Guardians. 

All rates, of whatever nature, are still levied through 
the overseers, and inasmuch as the electors of every 
district are determined by their position as ratepayers, 
the lists of voters both for Local Government elections 
and for Parliamentary elections are made out by the 
overseers, subject to further control into which it is not 
necessary to enter. 

It remains to give a short account of the machinery 
whereby the duties and powers are exercised by the 


Notes on the Machinery of Local Authorities 

The brief outline already given of the development of 
Local Government in this country, showed that the 
persons forming the body or Council responsible for 
carrying out the various duties are elected by the votes 
of the ratepayers. The inhabitants who will live under 
the government of the Council are responsible for placing 
those people in power who, in the opinion of themselves 
as ratepayers, will be the most suitable members of 
the Council. Each locality is in fact directly responsible 
for the events in its own district. If the ratepayers 
elect those who prefer economy to progress, they alone 
have done it. The control of the Central Government 
on most matters of general Public Health exists more 
in theory than i i practice. Latterly, however, the 
position has changed owing to the more modem develop- 
ments in connection with child welfare work in all its 
branches, and the work under the National Health 
Insurance Act. 

Further changes will probably become operative in 
the near future, under the schemes expected from the 
new Ministry of Health. 

The elections, in the boroughs, take place in the 
autumn, on November Ist, in time for the election of 
the Mayor, or Chairman of the Borough Council, by 
November 9th. One-third of the Council retire annually, 
and each member, being elected for three years, is eligible 
for re-election. 



In addition to the councillors there are aldermen, who 
are elected by the councillors. The aldermen are, for 
the most part, men who have had a considerable previous 
experience of service on the Council. The aldermen 
commonly remain in ofl&ce for six years — one-half 
of their number retire every third year. The number of 
aldermen is one-third that of the councillors, whose 
number is fixed for each town. The number of coun- 
cillors varies in the towns from nine to ninety, or more, 
and the number of aldermen varies in corresponding 
manner. In the Metropolitan Boroughs, the aldermen 
number one -sixth of the councillors, and not one- 

The Chairman of each Borough Council is termed the 
Mayor, and is a Justice of the Peace as well as Chairman 
of the Council. 

The procedure is very similar in urban or rural 
districts, but the electic n takes place in the spring, 
between 1st and 8th March, instead of in the autumn, 
and the Chairman of the Council has no special title. 
He is also a Justice of the Peace. 

In the case of County Councils, elections are held in 
the spring every three years, and all the members retire 
together. Continuity is preserved through the alder- 

The cost of the elections is charged to the rates. 

It is now necessary to consider the arrangements 
by which the councillors carry out the duties entrusted 
into their hands by the electors. Usually the councillors 
enter office pledged to carry out certain lines of policy. 
These lines of policy have been set out in their election 
addresses and speeches, and they have been returned 
by the electors in order to carry out this policy or 

The list of duties shown on pages 21 1 and 212 is formid- 
able, and it would be entirely impossible for the Council 
to discuss all matters for which the authority has the 


power of action. Therefore the Council works through 
committees, to which are entrusted the various branches 
of work. These committees do not possess executive 
powers, that is to say, they may not carry out the actions 
they recommend without the consent of the Council. 
There are some committees which have been laid down 
by Act of ParUament, and these are therefore known 
as Statutory Committees. The Council must appoint 
such committees. The Statutory Committees are at 
present few in number, and are not applicable to all 
areas. The number of other committees appointed by 
the Council to carry out the work of the district, if the 
district is of any size, is usually greatly in excess of the 
number of Statutory Committees. 

A few of the very small authorities may have so little 
work to do, and have so small a number of councillors, 
that the Council does not need any committees to whom 
it will delegate work. Such small authorities wiU prob- 
ably not be car'ying out duties in respect of which 
there is a Statutory Committee. 

The oldest Statutory Committee, introduced with the 
Municipal Corporations Act, is the Watch Committee, 
which deals with police matters, and is obligatory 
on those authorities having the control of police. It is 
composed of members of the Council only. 

In 1902 the Education Act made an Education 
Committee obligatory on those authorities which were 
to administer the Education Act. Authorities having 
such a committee are termed Local Education Authori- 
ties. There is, however, no separate authority for educa- 
tion, only a separate committee, which is subject to 
the general control of the Council just as are other 

The members of the Education Committee are not all 
members of the Council. The majority of the members 
are elected members, but the Council must co-opt other 
persons, who may be women, on to the Education 


Committee. Wliile the control of the committee is kept 
in the hands of the Council through the majority of 
members being councillors, there are introduced into 
the afEairs of the locality, persons who are appointed 
because of their special knowledge of educational 
matters, who are not pledged by election promises to 
carry out any special policy. 

In 1918 another Statutory Committee was laid down 
by the Maternity and Child Welfare Act. Here also, 
as in the case of the Education Committee, the majority 
only of members must be members of the Council, 
and the Council may co-opt other persons specially 
interested or experienced in the work. A further de- 
parture in this case is the fact that not less than two 
of the members must be women. 

The formation of these Statutory Committees gives 
indications of the general development of Local Govern- 
ment. The increase in the number of duties necessi- 
tates an increase in the number of committees, and the 
widening of the basis of membership. The details of 
the Maternity and Child Welfare Committee will be 
dealt with lower down. 

Practically all Local Authorities, other than the very 
small ones, have committees for Finance and for Public 
Health matters. With larger authorities these may 
be multiplied according to need, and have now become 
numerous and their arrangement complicated. Except 
in the case of Education and Maternity and Child 
Welfare, the members of the committees are all members 
of the Council.^ At the beginning of the municipal 
year, and immediately after the election, the new 
councillors are allotted to the various committees. 
Where the councillors and committees are numerous, 
it is common to have a General Purposes Committee, 

^ Joint Committees appointed imder Acts of Parliament between 
a Local Authority and other organisations are not here under 


which deals with this and other matters of similar 

There is no limit to the number of committees a 
Council may have. The details of the work of each 
committee, together with the number of members 
which shall form such a committee, are left entirely 
in the hands of the Council. The duties of the com- 
mittees and their methods of work are known as the 
standing orders, and these are laid down by the Council 
for each committee. 

There may also be sub-committees, formed either 
temporarily to consider special matters, or permanently 
to deal with items of the work of the main committee. 

The details vary for each district, but follow the 
general lines given above. 

A sufficient time before the rate to be levied for the 
year will be fixed, each committee is called upon to put 
forward estimates of the money it will require to carry 
on its work for the coming year. These estimates are 
then submitted to the Finance Committee, and after- 
wards to the Council. If no new work is being under- 
taken, the estimates are probably not questioned, but 
if additional expenditure is required, the cause of such 
expenditure will be explained; and the Finance Committee 
may reject the application, or may refer it back to the 
committee concerned with a request for amendment, 
reduction, or for further explanation, as the case may be. 
Ordinarily, if the expenditure has once been authorised 
for certain purposes up to a given limit, the committee 
is allowed to spend up to that amount without further 
supervision on the part of either the Finance Committee 
or the Council. If additional money is required 
during the year, then supplementary estimates are put 
forward in similar fashion, and must be passed by both 
Finance Committee and Council. There are, however, 
wide variations in the detailed procedure laid down by 
the diflercnt Councils. 


The ultimate control rests in all cases with the Council 
as a body. 

The Public Health Committee is not statutory except 
in the case of County Councils, but is found in every 
district of any size. The Medical OjB&cer of Health is 
attached to this committee, and the whole staff of the 
Public Health Department serve under it. The com- 
mittee deals with all matters arising under the Public 
Health Acts, and under any other Act that may be 
passed and where the Council selects that committee 
to undertake the work. Thus, when the inspection of 
midwives became compulsory under the Midwives 
Act of 1902, and was laid upon the counties and county 
boroughs, the latter laid the duty almost universally 
on the Public Health Committee, and, in the counties, 
a special committee was formed, since at that time the 
health work of the County Councils was in a more 
elementary state. As an instance of the latitude 
allowed to the Councils, it may be mentioned that, in 
one large county borough, the inspection of midwives 
was laid on the Watch Committee, and remained in the 
hands of that Committee until 1915. 

The Public Health Committee may have numerous 
sub-committees to deal with the different items, depend- 
ing entirely upon the local feeling as carried out by the 

In the early days of child welfare work the duties fell 
upon the Public Health Committees. They appointed the 
health visitors, and arranged the work which should be 
undertaken. The Notification of Births Act of 1915 made 
a sub-committee permissible, but only a comparatively 
small number of Councils appointed such a committee. 
If a committee was appointed, the Act provided for 
the co-optation of women. The Maternity and Child 
Welfare Act of 1918 made a committee compulsory. 
This committee might either be a separate committee 
of the Council or a sub-committee of the Public Health 


Committee. It may have co-opted members, and not 
less than two of its members must be women. The 
sub-committee or committee must contain a majority 
of members of the Council, If the sub-committee 
is made use of, it then reports to the Public Health 
Committee, which either approves or not, as the case 
may be. If approval is given, the Public Health Com- 
mittee then reports to the Council, or if money is con- 
cerned, the previous approval of the Finance Committee 
is necessary. Where a committee of the Council is 
appointed, the committee reports direct to the Council 
and not to the Public Health Committee. 

In counties it is more usual to appoint a separate 
Maternity and Child Welfare Committee, and to endow 
it with considerable powers. The County Council only 
meets quarterly, except for special occasions, and it 
would cause hopeless delay and congestion of business 
if considerable latitude were not allowed. In the 
boroughs, the Council meets much oftener, and greater 
control can be exercised. 

Power to spend money up to a given amount approved 
by the Council can be bestowed on the Maternity and 
Child Welfare Committee under the Act of 1918, and in 
some cases this is taken advantage of. The Committee 
may not, however, levy a rate. 

In county boroughs the inspection of midwives forma 
part of the maternity and child welfare work, and the 
provision of a midwifery service is one of the subjects 
which is demanding urgent attention. Where a mid- 
wifery committee already exists, steps will no doubt be 
taken to bring all the work under the Maternity and 
Child Welfare Act under the same committee. 

All the work undertaken under the Maternity and 
Child Welfare Acts will fall within the purview of the 
Maternity and Child Welfare Committee. The visiting 
in the homes, the work at the centre, the staff to be 
employed, the premises to be used, the co-ordination 


with the various agencies at work, and so forth. Very 
few of the Rural Sanitary Authorities have their own 
child welfare arrangements. Rural districts and small 
urban areas can be most economically worked through 
the county organisation as described in Chapter XI. 


The Sources of Money for Local Government 

A FEW references have already been made to the sources 
of money which can be utilised in connection with Local 
Government work. The financial aspect of Local 
Government is possessed of great interest and of much 
complexity. It is an ever-present factor in every branch 
of work undertaken, and often forms the determining 
feature in favour of or against the most important 
decisions of a Council. 

There are two main sources of money — that obtained 
locally from the rates, and that obtained centrally 
through the taxes. Of these two sources, the larger part 
of the money required for Local Government at the 
present time is derived from the rates. The rates have 
been referred to in connection with the Elizabethan 
Poor Laws, under which each district was called upon to 
provide the money necessary for its own poor. The 
money was levied by a charge on property, and the in- 
habitants paid a yearly sum varying with the amount 
of property held. The amount of money which would 
be required to meet the necessary charges was dis- 
tributed in proportion of the total value of property 
owned in the district. 

The early relatively simple rating system has now 
become extremely complicated. Different classes of 
property are differently rated, and the question of land 
valuation, and many other complex and abstruse prob- 


lems are closely bound up with the local rates. It is not 
necessary for the present purpose to enter into these 
more detailed questions. It is sufficient to remember 
that the rates are now levied in various forms on pro- 
perty, in the shape of land, houses, etc., and not on 
personal possessions, in the way of money, or on goods of 
any kind.^ 

The poor-rate, which was the first rate to be levied, 
has been repeatedly added to for the many numerous 
duties now laid upon the various Local Authorities. 
Some of the charges are levied under the term poor-rate, 
but much of the money is used for entirely different 
purposes. Other rates have been added from time to 
time and vary in different parts of the country. Many 
districts have special powers granted by Parhament 
which enable them to raise money locally from the rates 
for specific purposes. 

Ordinarily, in addition to the poor-rate, there will be 
at least one other rate, the borough or general rate, 
levied in the county areas. These rates are required for 
the numerous duties laid upon the different authorities, 
including education, sanitation, police, etc. 

Many boroughs have property which has been left 
by inhabitants of the district from time to time for the 
benefit of the body corporate. The income from such 
moneys is now inconsiderable in relation to the present 
expenditure, except in a few isolated cases, and need not 
be further dwelt upon for present purposes. 

Important variations are found in different districts 
in the amount of the rate per £ of rateable value, both in 
the total amounts, and in respect of the various rates. 
There are certain duties in respect of which a minimal 
expenditure must be made, but on many matters the 
Local Authority itself determines how far the various 

* The basis of valuation for the rate has varied from time to time. 
At the present time occupiers of agricultural land or clerical owners 
of tithe pay rates at one-half the assessment. 


services shall be developed, having regard to the cost 
which will necessarily be incurred. Thus, a Local 
Authority which studies the rates more than the health 
or convenience of the inhabitants, will have low rates — 
others again can produce a large sum with a small rate, 
owing to the great amount of valuable rateable property 
in the district, yet others have high rates owing to the 
amount of work undertaken. 

In all areas certain matters which have been regarded 
as pertaining to the State, rather than to the locaUty, 
have been paid for by the taxes, and not out of local 
rates. Such, for example, has been the charge in con- 
nection with certain matters of local administration of 
justice, etc., but, generally speaking, it is only com- 
paratively recently that the State has contributed out 
of taxes to the charges incurred in respect of what are 
ordinarily considered as directly local matters. 

Under the Local Government Act of 1888 a certain 
sum was contributed by the Government to local affairs 
out of money raised by taxes. This money was, in part 
at any rate, paid in consideration of a readjustment in 
respect of other items, notably the cost of justice, owing 
to the reorganisation arising out of the formation of the 
counties and county boroughs. Certain items of ex- 
penditure were mentioned as forming a first charge on 
this " Exchequer Contribution." At the time the con- 
tribution was inaugurated it proved a real contribution 
to the expenditure of the locaUty. The amount of the 
contribution has not increased, while the expenditure 
of the Local Authorities has done so. As a result, the 
Exchequer Contribution, while undoubtedly very wel- 
come, does not afford the degree of relief to local 
expenses which was originally the case. Since 1888 
other and more extensive arrangements have been made 
for aid from the Exchequer in the form of Treasury 
grants in aid. Before considering the special apph- 
cation of these grants to child welfare, a few remarks are 


necessary upon the sources of the grants j and the principle 
of their application. 

The money jQowing into the Treasury is raised from 
many sources. It is derived from customs and excise 
duties, from taxes of all kinds — on land, on income, 
on Ucences, etc., and, more recently, on such matters 
as excess proj&ts and entertainments. Each year the 
various Government departments are called upon by the 
Treasury to submit estimates of the expenditure they 
regard as necessary for the coming year. The Treasury 
may approve the estimates or may refer them back for 
alteration. If the Treasury agrees to the estimates, the 
sanction of Parliament must then be obtained, and the 
Treasury has to find the money required. 

Now the Treasury can only find the money by levying 
taxes in one form or another on the inhabitants of the 
country. The disposition of taxation, that is, the items 
on which the taxes are raised, is a very important matter, 
and must afTect the whole economic life of the country 
either favourably or adversely. Every one is more or less 
aware of the immense increase in taxation which has 
been necessitated by the cost of the war, and which has 
brought about an inevitable widening of the basis of 
taxation, together with a large increase in many of the 
former taxes. In addition to the war charges, there has 
been a wide demand for aid for local expenditure from 
the taxes, although the total amount is not large as 
compared with the cost of the war. The most costly 
item in aid of local expenditure will undoubtedly 
be the cost incurred in connection with the provision 
of houses, though at the moment the charge is not 

A heavy item of expenditure is the grants in aid of 
education, and the cost of the maternity and child 
welfare work is rising rapidly. Further claims in 
respect of charges connected with the National Health 
Insurance scheme, and, in other directions, demands 


for increased aid, and hence for increased levy of taxes, 
are continually being made. 

The propriety of grants in aid is open to question, 
and there are not wanting opponents of the whole 
system. Taxes draw money from sources untouched 
by rates, which sources should clearly be tapped for 
contribution towards the public needs. Some of the 
sources could be reached by an alteration of the basis 
of local taxation — namely, of the rates, but other 
sources of revenue would be difficult to deal with 

Government, through its various departments, is 
responsible to the country for the expenditure of the 
money raised, and it may not allot money to any purpose 
without ascertaining that the money so allotted is 
spent in conformity with the object for which it was 
granted. During the war there has admittedly been 
great expenditure of public money without due control, 
but doubtless such control will soon be resumed, and 
the general statement is not affected. 

If money is to be granted out of the taxes for the 
relief of rates, then the Government department, at 
whose request the money has been raised in the 
form of taxes, must see that the money is properly 
spent. The department must, in effect, supervise the 
work of the local authority in respect of the items 
towards which grants are payable. This introduces 
the system of inspection from the central department. 
The grants in aid are intended to raise and equalise 
the general level of work throughout the country, and 
no doubt this is secured in some measure. The bait 
of grants appeals with varying force to different 
authorities, and many of them would prefer to be left 
without grants and without inspection. With even 
the most regular inspection and pressure from the 
department concerned, it has so far been impossible 
to obtain anything approaching a uniform standard 


of work throughout the country in any branch of work 

Whatever the advantages and disadvantages of grants 
in aid may be, they have presumably come to stay, 
although it is not unlikely that the present methods 
of their administration may require modification as 
time goes on. 

Grants in aid are now payable in respect of educa- 
tion, through the Board of Education, in respect of 
health insurance, through the National Health Insur- 
ance Commission (recently transferred to form part 
of the Ministry of Health), of tuberculosis work, or of 
the treatment of venereal disease, and of maternity 
and child welfare work in all its branches. 

The contributions ordinarily extend up to 50 per cent. 
of the total cost incurred, but is higher (75 per cent.) 
in the case of venereal diseases. 

The local authorities concerned are required to 
submit their schemes to the Government department 
for approval, and any subsequent development under- 
taken must likewise receive approval in order to be 
passed for an increased grant. Inspectors are sent over 
the country to encourage the development of work on 
the best lines, and also to endeavour to bring back- 
ward authorities farther along the road to efficiency. 

The grants in aid are paid retrospectively on the 
known expenditure for the previous year, which ends 
on 31st March. The actual expenditure has to be 
incurred first by the local authority. 

The whole financial system is interdependent — locally 
and centrally, the one on the other, under the system 
of grants. The system is complicated, and the con- 
tinued demand for increased grants in aid will increase 
the complexity. Many people consider that there 
should be a block grant in aid of local charges, but that 
the degree to which a locality develops its work should 
be left to the locality without what is often termed 


" Government interference." In actual fact, the so- 
called interference is usually not resented by the most 
progressive local authorities, who are glad to show 
what they are doing, and to talk over the whole 
question with some one who knows what is being done 
in other directions. The term " adviser " would be, 
in many ways, preferable to " inspector " for those 
who travel round on behalf of some of the various 
Government departments, although advice is not 
possible without the detailed knowledge acquired by 
going over the work in the form of an inspection. 

After a careful survey of the work undertaken, the 
inspector makes a report to the department on the 
work, generally coupled with recommendations as to 
the payment of the grants. Each fresh object of grant 
necessitates further arrangement for inspection, and 
increases the charge on the Treasury. 

There appears to be an idea in the minds of some 
people that the Treasury has a bottomless purse into 
which a hand can be dipped, if only the Treasury will 
allow it. They do not realise that taxes as well as 
rates are levied on the nation, although from different 
sources. It is merely a question of which source shall 
be used for such purpose, and which fresh sources 
shall be opened up. 

In undertaking fresh developments for maternity 
and child welfare work, the local authority can, if 
the proposals are approved by the Ministry of Health, 
count on a repayment of one-half the cost, in the form 
of an Exchequer grant. 

The amount of money spent in this branch of work 
is rising very rapidly. Grants for child welfare work 
were first passed by Parliament in 1914, and only a 
few thousand pounds were required. Now the figure 
runs into hundreds of thousands for the Treasury 
grant, and involves the expenditure of a similar sum 
urom the local rates. 


Voluntary agencies are also eligible for grants, but 
are usually required to co-operate with the local 
authority in order to secure the money. 

No hard and fast rules are laid down as to the 
activities for child weKare which must be undertaken 
by an authority to secure a grant. Ordinarily, how- 
ever, the basic features of home visitation and work 
at the centre are required, although the latter alone 
may be arranged in the scattered rural areas. 

Loans and grants towards capital expenditure can, 
if necessary, also be secured from public funds. Sup- 
pose, for example, that a local authority wished 
to build a child welfare centre, assistance can be 
obtained if the plans and general arrangements are 
approved by the Ministry of Health. During the war 
all building was stopped, and no aid was available for 
capital expenditure. Building grants and aid for the 
purchase of a site will, however, probably be resumed 

Loans can be obtained from public money through 
the Public Works Commissioners, subject to the 
approval of the Government department concerned. 
Such a loan must be repaid within a fixed term of 
years. That proportion of the loan, together with the 
interest on the money, forms a charge on the rates 
until the whole is repaid. 

It is hoped that the above short notes may give 
an idea of the financial machinery which lies behind 
child welfare work. 


The Future 

Many of those who are engaged in child welfare work, 
or who have followed the progress of the movement, are 
asking themselves what the next developments of the 
work are likely to be. It would be foolish to be too 
sure as to the details of fresh activities of the movement, 
but there are not wanting indications as to the general 
lines which will probably be followed in the near future. 

In the first instance, the main hues hitherto worked 
upon need brief recapitulation. 

The movement started with the avowed object of 
decreasing the number of deaths among infants under 
one year of age. The accurate statistics which became 
available during the middle of the nineteenth century 
showed the terrible toll taken by death among the 
infants of the country. The root causes of many of 
the deaths were obscure, but there was evidently no 
means of securing any further information except by 
visiting the homes. The rise of the present system of 
Notification of Births and of home visitation has been 
traced in the preceding chapters, as well as that inter- 
dependent branch of the work carried out at the child 
welfare centres. 

Very early in the work it was found that it was not 
sufficient to take the single age period of 0-1 year. 
The medical inspection of school children began to 
show the mass of illness which supervened in children 
under five years of age, while, in fact, experience soon 



demonstrated that the child under one year could not 
be considered alone. The care for its health must 
continue up to and through school Ufe, and must extend 
backwards to its mother. The work for child welfare 
must link up on the one hand with that of the education 
authorities, and on the other with the whole midwifery 
service. An urgent need of the movement is the im- 
provement of the whole arrangements for midwifery. 
But this will undoubtedly bring out the damage already 
done to the mother's health at the time of marriage. 
Already voices are being raised in favour of demanding 
certificates of health in persons about to be married. 
It is not to be supposed that any such scheme could 
become effective, even if it were desirable. There 
should rather be a demand for a general improvement 
in the health of growing adults, so that the prospective 
parents of the country should be sound in body. 

In fact, the work for child welfare is only one of the 
numerous branches of work of the whole system for 
health. It must be increasingly linked up with the 
other agencies which are already in being, and with 
those avenues which will be opened up in the near 
future. Theoretically it is possible to divide hygiene 
into various branches, such as general or municipal 
hygiene, domestic hygiene, child hygiene, infant hygiene, 
and personal hygiene. Given other terms, these become 
the hygiene of the community, of the family, and of 
the individual at various ages. They are interdependent, 
and cannot really be separated. What is done by the 
child, or left undone by its parents, affects the health of 
the future generation. What is left undone by the 
community afiects the individual. No one can get 
away from the bonds which link him or her up to those 
among whom life is spent, or from the community in 
general. No one is an independent unit who can do 
what he or she likes with effects which will operate 
only on themselves. For good or ill they affect others 


morally and physically. Nor let it be supposed that 
it is only the married who affect the health of the futm:e 
generations. The actions and attitude of the unmarried 
of our generation will affect those of later ones. 

The supreme aim of the human race is happiness. 
All are striving after it, but each person will have his 
own dreams of what to him would, he believes, bring 
happiness. In whatever form that happiness may be 
encased, it is certain that a healthy body is of extreme 
importance, if not essential for its attainment. 

Health is a precious gift which the individual must 
be taught to use and to cherish. This brings with it 
the need for self-control, and may involve denial of 
many forms of desires. Because of this, health is too 
often flung away, and bitterly repented of at a later 
date. If, however, nature had no weaknesses, it seems 
likely that the health problem would not exist. We 
are as yet far indeed from such a state, and as a possi- 
bility it is almost inconceivable. But the health 
question must be dealt with as a whole. So long as it 
remains in separate compartments, as at present, so 
long will its progress be hindered. It is not enough 
to have a Ministry of Health which will co-ordinate 
the various branches of work. Those who carry out 
the work must extend their vision and increase their 
knowledge. They must be prepared to let their work 
become merged in the whole. The Unes of demarcation 
must be swept away ; while health work assists other 
branches of work for the community, it is conversely 
assisted by them. 

The spirit of communal life which is now ari ing in 
this country will undoubtedly prove of immense value 
to its health, and will help to secure the happiness which 
is desired by all. 





Record Sheet I 








Date of Birth 





















^ 6tb 





Got Sleep 
















Record Sheet II 


PrlTate and ConfldtatUL ^ 


RftI NO...U 

No ol Lua^r i.,. w ii.,i.. ■ii.^ ^„ i.^ u »M,..- ^ ^. .^^^.fUatu ot brsi Vrkit ... 

bBmiai7 m«tr«r^ ^, -^,.mi,^ w , ..iV, . n'Mtr ot kut \H{l^n«. 

MotlMr. Nunt . 

Aee.,»«.„.i.......«r«,.vr.-i«^ .^».....KHCt and Nattonality --. rw-i 

Livuig trith kuib*iid Lmng o^art. Wtdoved Unmantti 

Ocnenil Health Good. Indt§aent, Bad 

Chafacicr ot ConRnemcnL 

D»cUr. Midmfs tnstuattm. 

I'reviouft Histof7 No of Miscitmagcfc .•*■..■*». '.•.-^> ^rcfOfi^Cin Utnhi-u., 

Children bom abvr... ^,.^ — .r.«,Non tivinx.u„,.„.,.^...Mf.,..Dicd in Ui ]rv< 

Docription ol wofk before pfcaciH pfcgwancy .. im^...4*«.»«mwm. ■.»•«— .-^'t^. 
Otlier information.,.. ..'.««.,„^.. u«a 



Work during pnpiancj Mow lone cencd before fttnh i » i ■ ■ » m mum i 

Pr«CIM OCCUpatkW^^n..' t..-..^.. I. MM-. ..»..*. 

CvntJ M at kern*. In fmttff tf MfrJkf A*/. Elumifm. 

Weekly earning*.,...^.. .^ »..,._-.Malure ol work Htat^, UtUi 

Speciel condhioo«....^«..»w.„.,i«..^..M.u..— .. ».in«.. ■«.».« 
Work utter birih. Ke»ua>c4k,..,.».>.^..wri>»ed(« alU( birth. 

Why fe»uiBe<t...>wt4*a>a>»fu» .>' 

PrcciM occ<ipalioi>..>u.w~.._., n<_< 

CarrMi»e<faM<. Im fttttfi wttkUttf^ Blwrtm. 

Weekly rarnin(> ......r.... -Mwurt ol work. UMey U»til 

ChlM. Full Nunt ^ .■»».....^........., „»....— »..,.»..,.-.^.U>»W ol Unhn.^.^ 

Utl4 ftmsU. Lijilimt)!. llUtUml: Ftrthm. Ptnutm: Fall Inu. 
Condilionet hctl »nit ••( -..™..»*llMI~, u...^..-..—.. 

I( dcelh oociiri, «t« H death - ■ » o -» »..» X:«me ol de«l> .,...„_ .^— . ■ ' 

Ftednn durtnt ttn «i» monUn ot lite. 

Brcail entirely lor........ „—'>■».«*•>■* 

ArtlAcMil l<icd pertly ibKa>.. .....»..■>. .^.t.-, -t WliylM«..«.....-.-.-..~ . ■ — — ii m . »r». 

AftUkW rood entirriy tine* ...-..., n«...«f Wby}.~.......M.K.<' ■ " ■ -m ourn 

'NuUW. BymMm By lift fmim tt htm fWwfc »b«f«»— ..a.— ... , .,i., „n ..- ■.-■ ..^.■^.■■■■■ii— ^m.~ 

t UMtar ilHMMedHwe ike^i^ te Me Um reeeeM *i i tn liilil tneM leaAoft eteuy > pu%.<«.,OT«nle4M> 
Man ^ alft. MeasfUw ri MikeeleUe^eaHk ttt. 



fttbw. OccuiKtioo ., 

Rao »ik1 Nalionaliljr..; 

Health. J^xii. Itdifirmtt. BU. 

Horn*. lUni -.,.-... 

Condjtioo .^ 

Na of family at home 

Ho, of \n^ffi\^ 

. Waekly aamingf.. 

No. o< Rooms.. 

Waeldy (ncooM ol (HnOy.. 



How tn 


Ho* PtD 


Record Sheet III 

Name of Infant 
Address ... ... 

Date of Blilh ~™,.~^. 

Age at 1st Consultation 

..,.„. No ..t. 

Weigh! ~.-" 

Weight -. 






tdcad ' Af 


Cause ot d«ath 


Age at Marriage . .«,»....-.„ ... 

Age ai Ui Conflnemant...^ 

Age at birth of this child . . 

Health . _....™. .. 

Savers I11iimms.„_ — ...,..i..».,— ..—-..— ..,. 

TttberciilosU»».> .».»».■..... I.... < ~r- -~~ 

Periodicity „~..„._...m~-~^ 

Duration ... .... 

During Lactation 


ConanluihM . 
Vlallor - , -. 
MysMM ... 


Age at Marriage ............. 

Age at binb o< 1st chU4.... 

Age at birth of thia child ..... 

-Health ..,...-«,.v...„....«. 

, Ssvere lUotsaae.. 

Nature ._ 

Regularity _..,._ 

Before birth of child... 
Sines birth ot chlld^,.. 

Average Wag*.. 
Rent .....>«...._ 

No. of Rootn(..>._ 

Floor II 

No. at Occupaatt._«.. 










Phytteiftfi'a NdU>. 


Add res 

Date of Birth 


Montf» of Ao« 
iVMk* at Aga 

T««t ratttf* 

r iM. 

• M* 

• Mi. 

1 1 i 4 1 1 1 »»•»"« " 

1 2 3 4 5 « 7 « Jl» 11 11 m4 HJ1« 1? 11 » JO r U okt 25J6n2(ffl3(l|3132a3(35a373836««e43»<6<6«7««?S0|MB 

J_ , 1 1 

■ y ^ ^ J 

- ^^ 

_ _ _ 

— , 

- - - - _ .^ 

— " - _- - - - ^ 

— :::i:?:_- z 

__ — -_ ... .._. _ - 

" _:: :::::_:_:_:: :: i-..^ 

--.- ,> 

i_ __ ,2: _ -. 

-- - - ::_:::: :?__ :_ . 

— - — - — ; ;:: ^i 

.___-_-_ ._.^-__-._ 

--- ■" •■ _-^_ - ;- 

- - - ±' ~ "_ -"' : : :?_: - _. 

___ -_- - . - _ - ^ 

-.-^^-. -.--.----- _ _ 

-_r - - - - - __ :;z__ _ _ __--_-- 

_ - — _~2;;:_:_:_ 

± :::?::::::::::: _ 

' -- -- - '2 - __ _x _ - 

_ _ _ _ __ .^_ __ 4- 

— I _ ::__!;: i 

1 - / :::::::: ::_i:_ __ 4: . 

1 r 

::::;_::::_:::::. ::!J::_;:::-;i- -in:- :ii:iiiiii--i-- 

— i — : — : i^t""---!^"-- - - __ - - -- 


^ :_:__:: ::_: :~ :::"::__: : _ 

ii ? — 

_. " 7 _. 

Z. - ______ _--__^ 

_ .e_ _______ _____-._ -__p-__ 

-^ _____..___.__-_--_--------.-. 

— -J ;:::::i:::::.: t 

— '.izz'ilzzz'.zzzz'.ziizz'.zzizizi'.'.y. 

riT A 111- 

— --r — 12 . _, 


— / ::::::::;:::::::: 

— i^----------------------------------- 

---f ■ — -- : 11: "nil"-' 



"/:ii:::z::::i;;;;:ii;iii;ii--i - 

y-t : : — :::::::::""":ri!" z 

t — " ::::::::::;::i.:i_::i 




Work among Children under Five. 

The importance of work among children between two and five 
is shown by the figures of ailments found among entrants on 
medical inspection, taken from the Report of the London County 
Council for 1918. 

The figures are not complete for the whole country, but the 
figures for London given below do not diflFer very materially 
from those in the Board of Education Report for other parts. 

TABLE SHOWING THE Result of Medical Inspection in 
London Elementary Schools. 

Number examined — 77736. 


Skin diseases . 



Enlarged tonsils 

. 13108 


Adenoid growtlis 



Tonsils or adenoids . 



Other throat or nose defects 



Enlarged glands of neck . 



Dental defects 



External eye disease 



Ear disease 



Defective hearing 



Stammering . 



Other speech defects 



Heart defects . 






Lung complaints 



Nervous diseases 



Phthisis .... 



Other tuberculous disease 



Rickets .... 






Infectious disease . 



Malnutrition . 



Other defects . . . . 





GEO. 5), 1918, WITH CIRCULARS 4 AND 11 


An Act to make fubtheb Peovision fob the Health of 
Mothers and Youno Children. 

[8th August 1918.] 

Be it enacted by the Bang's most Excellent Majesty, by and 
with the advice and consent of the Lords Spiritual and Temporal, 
and Commons, in this present Parhament assembled, and by the 
authority of the same, as follows : — 

Powers of Local Authorities ivith respect to Maternity and Child 
Welfare (7 Edw. 7, c. 40). 

1. Any Local Authority within the meaning of the Notification 
of Births Act, 1907, may make such arrangements as may be 
sanctioned by the Local Government Board, for attending to 
the health of expectant mothere and nursing mothers, and of 
children who have not attained the age of five years and are not 
being educated in schools recognised by the Board of Education : 

Provided that nothing in this Act shall authorise the estab- 
lishment by any local authority of a general domiciUary service 
by medical practitioners. 

Maternity and Child Welfare Committees (5 & 6 Oeo. 5, c. 64). 

2. — (1) Every council in England and Wales exercising powers 
under this Act or under section two of the Notification of Births 
(Extension) Act, 1916, shall establish a maternity and child 
welfare committee, which may be an existing oommitteo of the 
council or a sub-committee of an existing committee, and all 
matters relating to the exercise of the powers of the council imder 


this Act or under the Notification of Births (Extension) Act, 
1915 (except the power of raising a rate or of borrowing money), 
shall stand refen-ed to such committee, and the council, before 
exercising any such powers, shall, unless in their opinion the 
matter is urgent, receive and consider the report of the maternity 
and child welfare committee with respect to the matter in 
question, and the council may also delegate to the maternity 
and child welfare committee, with or without restrictions or 
conditions as they think fit, any of their powers under that Act 
or this Act, except the power of raising a rate or of borrowing 

(2) The council may appoint as members of the committee 
persons specially qualified by training or experience in subjects 
relating to health and maternity who are not members of the 
council, but not less than two-thirds of the members of every 
maternity and child welfare committee shall consist of members 
of the council, and at least two members of every such committee 
shall be women, and where the duties of the maternity and child 
welfare committee are discharged by an existing committee 
or sub-committee any members appointed under this provision 
who are not members of the council shall act only in connection 
with maternity and child welfare. 

(3) The committee established under this section shall take 
the place of any committee appointed under subsection (2) of 
section two of the Notification of Births (Extension) Act, 1915, 
and the provisions of that subsection relating to the exercise 
of powers by a committee shall cease to have effect. 

(4) A committee established under this section may, subject 
to any directions of the council, appoint such and so many sub- 
committees, consisting either wholly or partly of members of the 
committee, as the committee thinks fit. 


3. The expenses of any council in England and Wales under 
this Act shall be defrayed in the same manner as expenses under 
the Notification of Births Acts, 1907 and 1915, and the pur- 
poses of this Act shall be purposes for which a sanitary authority 
in London may borrow under subsection (2) of section one hun- 
dred and five of the Public Health (London) Act, 1891 : 

Provided that a county council may, if they think fit, charge 
all expenses under this Act or those Acts as general county 
expenses subject to the condition that, if any district council 
within the county has provided for its district a similar service to 
that provided by the county council for other parts of the county, 
the county council shall pay to the district council the amount 


raised by the county council in the district in respect of such 
service. Any question that may arise between a county council 
and a district council under this proviso shall be determined by 
the Local Government Board. 

Amendment of Section 3 o/ 5 & 6 Geo. 5, c. 64. 

4. Section three of the Notification of Births (Extension) Act, 
1915, shall be read as if the following words were inserted at the 
end of paragraph (&) of subsection (1) and paragraph (6) of sub- 
section (2) thereof, namely : — 

" and for the purpose of any such arrangements may, subject 
to the sanction aforesaid, exercise the hke powers as they are 
entitled to exercise for the purpose of the provision of hospitals." 
6. — (1) This Act may be cited as the Maternity and Child 
Welfare Act, 1918. 

(2) This Act, except the section thereof providing for the 
amendment of section three of the Notification of Births (Ex- 
tension) Act, 1915, shall not apply to Scotland or Ireland. 

Circular (M. & C. W. 4). 

County Councils {other than the London County Council) 
and Sanitary Authorities. 


Local Government Board, 

Whitehall, S.W.I, 

9th August 1918. 


1. I am directed by the President""of the Local Government 
Bofiurd to bring to the notice of the Council the provisions of the 
Maternity and Child Welfare Act, 1918, which has recently 

The Act widens the powers of Local Authorities in the matter 
of maternity and child welfare. It enables them to make such 
arrangements as may be sanctioned by the Board for attending 
to the health of expectant mothers and nursing mothers and 
of children who have not attained the age of five years, and 
are not being educated in schools recognised by the Board of 

A Council exercising powers under the Act must appoint a 
Maternity and Child Welfare Committee. This Committee may 
be specially appointed for this purpose or may bo an existing 
C)ommitteo or a sub-Oommitteo of an existing Committee, and 


it must include at least two women. Subject to two-thirds of 
the members of the Committee being members of the Council, 
persons specially qualified by training or experience in subjects 
relating to health and maternity who are not members of the 
Council may be appointed as members of the Committee. A 
Committee appointed under the section may also appoint sub- 
committees consisting wholly or partly of members of the Com- 
mittee. Mr. Hayes Fisher considers it is important that working 
women should be represented on the Committee. In seeking such 
representatives the local branches of working women's organisa- 
tions or the Standing Joint Committee of Industrial Women's 
Organisations, 33 Eccleston Square, London, S.W.I, might 
usefully be consulted. 

2. The supreme importance of Maternity and Child Welfare 
work at the present time needs no emphasis. With a view to 
encouraging the provision of further services, which experience 
has shown would be of value for conserving infant lives and 
health, Mr. Hayes Fisher has obtained the sanction of the 
Treasury to a considerable extension of the scope of the Board's 
grant. A copy of the new regulations is appended to this 

The additional services for which the grant is now available, 
subject to the Board approving the arrangements, are, chiefly : — 

Hospital treatment for children up to five years of age. 

Lying-in homes. 

Home helps. 

The provision of food for expectant and nursing mothers and 
for children under five years of age. 

Creches and day nurseries. 

Convalescent homes. 

Homes for the children of widowed and deserted mothers and 
for illegitimate children. 

Experimental work for the health of expectant and nursing 
mothers and of infants and children under five years of age. 

In certain other respects the scope of the grant has been 

With a view to assisting Local Authorities and Voluntary 
Agencies in developing this work, the Board submit the fol- 
lowing comments. These should be read as supplementing the 
observations made in earlier circulars. 

Administrative Arrangements. 

3. In their original Circular of 30th July 1914, on the subject 
of this grant, the Board stated : — 

" For the rural and smaller urban areas the Board think it will 


fenerally be found desirable to develop a county organisation, 
ut in all cases the county work should be intimately related 
with that of the local sanitary authority, and on the other 
hand any work separately undertaken by a. sanitary authority 
should be co-ordinated with the county scheme." 
The Board may also draw attention to the foUowing obser- 
vations, which were contained in their Circular of the 29th July, 
1915, in regard to the Notification of Births (Extension) Act, 
1915 :— 

" The Act contemplates that arrangements for attending 
to mothers and young children may be made either by County 
Coimcils or by sanitary authorities. The Board recognise 
that the organisation must vary to some extent with local 
conditions, and that a considerable degree of elasticity is neces- 
sary. They are, however, of opinion that it wiU generally be 
desirable to formulate comprehensive schemes for coimties 
and county boroughs, although in some cases portions of the 
services may be undertaken by the larger District Councils 
with advantage. The councils of counties and county bor- 
oughs are the local supervising authorities under the Midwives 
Act, 1902, and they are also entrusted with the initiation 
and execution of schemes for the treatment of tuberculosis ; 
if the organisation of a mateinity and infant welfare scheme 
is also undertaken by them, it will be practicable to secure the 
unification of home visiting for a number of different purposes. 
" In all cases, however, in which a general scheme is organ- 
ised for the county, the work should be carried on in close 
co-operation with the sanitary authority." 
As a general rule, County Councils have adopted compre- 
hensive schemes for all the districts in their counties, except 
those which by reason of their population and number of births 
can properly form separate units for these services. Some 
smaller districts are still carrying on separate schemes, but the 
most advantageous course usually lies in the amalgamation of 
these schemes with the county scheme, and Mr. Hayes Fisher is 
slad to observe that the Councils of many of the smaller districts 
have agreed to amalgamation and are co-operating with the 
County Council in this work. Where this has occurred the 
County Council have generally continued the work of the local 
sanitary authority with the staff previously employed by the 
smaller authority, and have availed themselves of the assistance 
of that authority and of their Medical Officer of Healtli in carrying 
it out. 

The work to be done is of a composite character, and, while 
some parts of it may in certain cases oe satisfactorily undertaken 
by the smaller authorities, other parts should be undertaken by 


the County Council, and it is therefore desirable that the smaller 
District Councils should in all cases consult the County Council 
before considering the provision of separate services. 

The County Council and the District Council have concurrent 
powers, in order that for all parts of the work the most efficient 
arrangement may be made, but the Board look to the County 
Council to consider the needs of the County as a whole, and 
how these needs may best be supplied. 

The Board request that each County Council Avill take this 
subject into early consideration, and that they will prepare 
and submit to the Board a report on the work now being under- 
taken, on the new services which should be established, and on 
the methods whereby the new services can best be provided. 
It is important that the County Council in preparing their report 
should confer with the District Councils in order to secure their 
co-operation at every stage. 

Inspection of Midwives. 

4. In the Board's view each midwife in the district should be 
seen by the Inspector of Midwives of the Supervising Authority 
not less frequently than once a quarter, at least until the In- 
spector is satisfied that the midwife will carry out her instructions 
satisfactorily. Special inquiries should be made if there is any 
doubt as to the satisfactory character of the widwifery 8er\'ice, 
and prompt visits should be paid and reports made to the Medical 
Officer of the Supervising Authority in such cases notified under 
Rule 20 of the Central Midwives Board as may be determined 
by him, and especially when there is a rise of temperature in 
the mother or a discharge from the eyes of the infant. 

It is important that the visits of inspection should be made 
the occasion for giving general instruction and assistance to the 
midwives. The Supervising Authority should therefore appoint 
a sufficient staff of competent inspectors. The Board consider 
that an Inspector of Midwives should, if possible, be a qualified 
medical woman ; if this cannot be secured, she should be a 
certified midwife with sufficient experience in the practice of 
midwifery. It is important that the Supervising Authority 
should in all cases secure co-operation between the midwives 
and the local organisation for maternity and child welfare work. 

Provision of Midwifery. 

5. The object of the Board's grant in aid of midwifery is to 
secure that as far as is practicable there shall be an efficient 
midwifery service throughout the country, and the Board look 


to the Councils of Counties and County Boroughs to organise 
arrangements for securing this. In the Board's opinion it is 
important that the status of midwives should be raised, and 
that competent trained women who devote themselves to this 
service should be adequately remunerated. Unless this is done 
the Board are satisfied .that an efficient midwifery service will 
not be established and maintained. The Board consider that 
a competent trained midwife, devoting her whole time to the 
work, should be able to secure at the present time an income of 
from £120 to £150 a year. 

6. The Board have indicated that a local authority may pay 
or guarantee the salary of a competent midwife, and they are 
willing to consider any scheme for improving the midwifery 
service which may be submitted. 

In cases in winch a council provide or arrange for a general 
midwifery service they should fix a general scale of fees, but 
these may be reduced or remitted in individual cases where the 
circumstances justify this course. In so far as the fees received 
do not meet the cost of this service, the Board are prepared, 
subject to their prior approval of the scheme, to find one-half of 
the deficiency. 

7. In sparsely populated districts where the midwife is sup- 
ported by a Nursing Association, the Board will base the grant 
on the number of cases attended during the year, either by 
midwives or maternity nurses. They will pay a grant to County 
Nursing Associations in respect of 

(a) the establishment expenses of the County Nursing Asso- 
ciation attributable to midwifery, 

(b) the midwifery and maternity cases attended by (1) nurse- 
midwives of affiliated associations, (2) emergency nurse- 
midwives of the County Nursing Association, and 

(c) the expenses of the County Nursing Association and of 
affiliated District Nursing Associations in starting new asso- 
ciations where there is no competent midwife. 

County Councils may make contributions to County or District 
Nursing Associations for these services, and where they do so 
the Board will make a grant in respect of their expenditure. 
They will also make a grant on the same basis to County Councils 
in rcflpect of the midwifery and maternity nursing provided by 
unaffiliated associations, but they recommend that such associa- 
tions should become affiliated to the County Nursing Association. 

8. In districts with a largo population it is possible for the 
practice of midwifery to be more nearly self-supporting than in 
more scattered areas. Novci-thclcss, a number of midwives are 
maintained in these localiti<s by hospitals, maternity charities, 
and diHtrict nursing asitociations, and their sorviues are provided 


at less than the ordinary fee of the district for women who 
cannot afford to pay this fee. Moreover, in many cases the 
ordinary fee is not sufficient to provide a competent trained 
midwife with an adequate income. The Board's grant is avail- 
able in respect of the loss on district midwifery, if any, made 
by these institutions, and it will amount ordinarily to half the 
deficit on the service. 

9. In all cases the grant in respect of midwifery will be subject 
to the following conditions : ( 1 ) that the Board are satisfied that 
the midwife is competent, (2) that her services are available in 
respect of all women who need them, and (3) that the ordinary 
fee of the district is charged, and that it is only reduced or 
remitted where the circumstances of the case justify the adoption 
of this course. 

10. A Local Authority or Voluntary Agency may provide a 
midwifery outfit for any midwife employed or subsidised by 
them. The outfit should be retained if the midwife leaves the 
service, and should be given to her successor. The grant is 
available in respect of this expenditure and also of the cost of 
maternity outfits (apart from bedding) lent by a Local Authority 
or Voluntary Agency to lying-in women in cases where this is 

Doctors' Fees. 

IL The Board trust that all Local Authorities carrying out 
Maternity and Child Welfare Schemes will arrange to pay the 
fees of doctors when called in by midwives during the period of 
confinement. In cases which are not necessitous the persons 
concerned would no doubt be willing to bear or repay the cost, 
but it is important that the doctors called in should be able to 
look to the Local Authority for their fees where the persons 
attended are unable to pay, and that they may be so informed. 
Local Authorities should ascertain wluch of the general practi- 
tioners of the district are willing to undertake to respond to the 
call of a midwife, and should, if possible, arrange that one of 
them shall always be available to answer an urgent call. The 
midwives should be furnished with a list of the doctors who are 
willing to attend. 

Health Visitors. 

12. As a result of their further experience, the Board con- 
sider that the standard of 600 births to each Health Visitor, 
which they have previously suggested, should be modified. The 
functions of a Health Visitor should comprise the visiting and 
supervision of all children under school age in the district needing 
this attention ; the visiting of expectant mothers who have 


attended at an Ante-natal Centre, or for whom visits are de- 
sirable ; inquiry into still-births and the deaths of young chil- 
dren ; and attendance at the Centre to which women and 
children, including those whom she has visited in their homes, 
come for medical and hygienic advice. Where these duties are 
fully performed it appears to the Board that a district with 
about 400 births a year will be as much as one Health Visitor 
can undertake, unless the district is very compact, or is of such 
a class that many infants do not need visiting. The Health 
Visitor's district should where practicable be so arranged that 
it is served by one Centre. 

Qualifications of Health Visitors. 

13. It is not practicable at the present time to prescribe a 
special course of training or a standard examination for Health 
Visitors generally. The qualifications prescribed by the Board's 
Order of 1909 with regard to London are : — 

(a) A Medical Degree, or 

(6) The full training of a nurse, or 

(c) The certificate of the Central Midwives Board, or 

(d) Some training in nursing and the Health Visitor's certifi- 

cate of a Society approved by the Board, or 

(e) The previous discharge of duties of a similar chariujter in 

the service of a Local Authority. 
The certificate of a sanitary inspector is also valuable. In the 
absence of one or more of these quaUfications, the Board are not 
prepared to pay a grant in respect of a Health Visitor's salary 
unless they have adequate evidence before them that she is 
qualified for this work. 

14. Other offices, such as that of Tuberculosis Nurse, School 
Nurse and Mental Deficiency Visitor, may be held with that of 
Health Visitor in certain cases, so as to give the officer a compact 
district, save the time and money spent in travelling, and reduce 
the number of inspectors who may have to visit a particular 
house. The salary of a whole-time officer acting as Health 
Visitor with or without these other posts should as a rule be not 
lees than £120 a year. 

District Nurses as Health Visitors. 

15. In sparsely populated districts it may be convenient to 
appoint the district nurse-midwives of Nursing Associations as 
Health Visitors, if the Medical Officer of Health is satisfied that 
they are competent to perform the work. In some cases it may 
be found practicable to give the nurse-midwives special uistruc- 


tion and training in the work of a Health Visitor. More than 
half the County Councils are now using district nurse-midwives 
as Health Visitors. The advantages of employing them are that, 
as a rule, they are well known and well received by the women 
in a counti-y parish, that their advice is readily accepted, and 
that the arrangement may obviate duplication of inspection, 
and save time and money spent in travelling. 

16. Where nurse-midwives employed by Associations affiliated 
to the County Nursing Association are employed as Health 
Visitors, the Coimty Council and the County Nursing Association 
may find it advantageous to combine the offices of Superinten- 
dent of the County Nursing Association, Chief Health Visitor 
and Inspector of Midwives, so that the nurse-midwives are 
inspected by one official in all capacities. 

Visiting by Voluntary Workers. 

17. In a few districts voluntary workers, generally without 
full training, engage in health visiting. Their work should 
always be done in connection with that of trained and paid 
officers, and they may usefully assist at the Centres and in the 
supervision of older children. 

Appointment of Health Visitors as Infant Protection Visitors under 
the Children Act, 1908. 

18. The Local Authority under the Children Act, 1908, is in 
London the Count}'^ Council, and outside London the Board of 
Guardians. It appears to the Board desirable that, where 
practicable, the Health Visitor and the Infant Protection Visitor 
should be the same person, and they suggest that the Local 
Authorities appointing Health Visitors should consult with the 
authorities appointing Infant Protection Visitors in their areas 
with a view to securing this. 


19. The home nursing services in respect of which the grant 
is now available are nursing needed for expectant mothers, 
maternity nursing, the nursing of puerperal fever, and the 
nursing of measles, whooping-cough and epidemic diarrhoea in 
young children, and of ophthalmia neonatorum. 

20. The maternity nursing should be undertaken by a woman 
with the certificate of the Central Midwives Board : faifing this 
quahfication, the Board should be furnished with evidence of 
her competency if a grant is claimed. A scale of fees should be 


fixed for maternity nursing, but the charge may be reduced or 
remitted in individual cases where circumstances justify the 
adoption of this couree. 

21. The Local Authority may, with the consent of the Board, 
themselves appoint nurses for the purposes specified above, or 
may contract with a body such as a District Nursing Association 
for this service. Where they appoint a special nurse, her spare 
time may well be utilised in the ordinary work of a Health 
Visitor. Often it is more convenient to arrange with a District 
Nursing Association for the services of one of their nurses to be 
available when an infectious disease prevails. Most district 
nurses are now allowed to nurse the cases of the infectious 
diseases mentioned in paragraph 19, subject to their taking 
simple precautions, as to which the Medical Officer of Health 
can advise. The Local Authority may pay a retaining fee to a 
District Nursing Association for the purpose of securing that a 
nurse is always available, and in addition pay a fee per visit or 
per case. It is particularly important that all cases of measles 
notified from districts in which deaths from this disease are 
likely to occur should be visited by a Health Visitor. On her 
report the Medical Officer of Health can usually decide when 
nursing is required. 

22. In districts in which the County Council undertake the 
Maternity and Child Welfare work it is convenient that the nurses 
should be employed by the Council either directly or through the 
County Nursing Association. Under this arrangement the 
nurses are available for visiting and nursing in any district in 
which a nurse is needed. 


23. The number of Centres has increased considerably during 
the past year, and much credit is due in this matter to private 
enterprise. Every Centre, whether municipal or voluntary, 
should generally be supervised by at least one trained and 
salaried^ worker, but unpaid workers interested in its objects can 
be of great assistance in weighing babies, in entertaining the 
mothers, and in giving instruction in elementary hygiene, 
cookery, sewing, etc. Where practicable, there should be a 
Centre for each Health Visitor's district, and the Health Visitor 
should attend when the Centre is open in order to be able to 
■uperviso the subsequent adoption at home of the advice given 
at the Centre. 

The chief value of the Centre is to provide medical and es- 
I)€cially hygifmic advice. Mothers should be urged to bring their 
children, whether ailing or not, for such advice and for periodical 


weighings. At the present time doctors are so fully occupied 
that regular medical attendance at many Centres is impossible, 
but every effort should be made to secure the attendance of a 
doctor, if not at every meeting, at any rate not less often than 
once a fortnight, or, in small Centres, once a month. Medical 
attendance should be regular and uniform, i.e., the same doctor 
should attend at stated intervals. The Board do not recommend 
a rota of doctors ; subject to this the doctor may be a local 
practitioner, the Medical Officer of Health, or the Assistant 
Medical Officer of Health. K the medical officer of the Centre 
is an officer of the Local Authority, he or she should be paid a 
separate salary for this work. It is desirable that Local Auth- 
orities should consult the local medical practitioners before 
making arrangements for medical atendance at a Centre. 

24. Cases which are found at the Centre to need anything 
beyond minor treatment should be referred to their own medical 
attendant, or, if the woman cannot afford a doctor, to a hospital, 
if a hospital is available. One Centre may suffice for the treat- 
ment of cases from a number of Centres, and such a Centre may 
be combined with a school clinic, especially for ophthalmic and 
dental cases. A dental clinic should, wherever practicable, be 
available for expectant and nursing mothers and for children 
under five. The grant is available in respect of reasonable 
expenditure on treatment at Centres, including the treatment of 
ophthalmic and dental cases. A charge should ordinarily be 
made for new dentures for women and for spectacles for children, 
but the Board are wiUing that the charge should be reduced 
below the cost price or remitted entirely where the circumstances 
of the woman or of the child's parents are such as to justify this 

25. The Board have had under their consideration the question 
whether cots may be provided as a part of the equipment of a 
Centre, and after conference with the representatives of a number 
of hospitals and volimtary Centres, their Medical Officer has 
advised that, subject to certain conditions, they may be allowed. 
The anangements wiU be subject to revision in the light of 
experience ; for the present they should be generally in accordance 
with the following conditions if a grant is desired : — 

1. Acute cases of illness, such as would ordinarily be ad- 
mitted to existing hospitals, and cases of infectious disease 
should not be treated in cots at a Centre. The Centre should, 
if practicable, be associated with a General Hospital or a 
Children's Hospital, with a view to prompt admission of acute 
or serious cases of illness. 

f 2. The experiment of providing cots at Centres should be 
on a small scale, with not more than two wards with four cots 


in each, and the fittings and furniture should be as simple and 
inexpensive as possible. 

3. A whole-time nurse should be in charge by day and one 
by night, and the nursing staff should, as a rule, be distinct 
from the staff engaged in the ordinary work of the Centre. 

4. If a medical officer is not resident on the premises there 
should be arrangements for securing his prompt attendance 
when required in emergency. 

The Board would welcome arrangements for the treatment of 
mothers with their infants when breast-feeding fails. For this 
purpose it may be necessary for both mother and infant to 
become in-patients. In other instances the infant may be 
admitted, the mother attending twice or three times daily in 
a separate room to give supplementary breast feeds. 

Instruction in Hygiene. 

26. The extension of the grant to this purpose has been made 
in order to make it available in aid of reasonable expenditure on 
literature, exhibitions, and on collective instruction to expectant 
and nursing mothers, and also to voluntary and salaried workers 
where the Medical Officer considers that the instruction is likely 
to improve their competency to undertake the Maternity and 
Child Welfare work assigned to them. The expenses of salaried 
workers engaged in such work may be included in the application 
for grant under this heading. 

Provision for Confinements. 

27. The Board are satisfied that in many areas additional 
lying-in accommodation is reqiiired for normal as well as ab- 
normal confinements, and they have therefore obtained power to 
make a grant to encourage the provision of such accommodation. 
The grant for this service will as a rule be paid only to a Local 
Authority, as the Board look to the Local Authority to provide 
or arrange for the provision of the accommodation required. 
Voluntary societies providing homes for normal confinements, 
if they need financial assistance, should, as a general rule, apply 
to the Local Authority in whose district the institution is situate. 

In order that such homes may be eligible for the Board's 

gant, they must be willing to receive cases in whicli the Medical 
fBccr of Health of the district considers that admission to the 
home is desirable because of domestic conditions. 

A scale of charges should be fixed for the use of the Ijnng-in 
home» but the charge may be reduced or remitted in individual 


cases where the circumstances may justify the adoption of this 

Home Helps and other Assistance. 

28. In many cases a woman is unwiUing to leave her home, 
even if its conditions are unsuitable for her confinement. If the 
difl&culty arises from the number of children, arrangements may 
sometimes be made for the children to be boarded out during 
the mother's lying-in period ; if it is due to the need for a person 
to look after the house during this period, whether the confine- 
ment takes place at the home or elsewhere, a Home Help may be 
supplied for the purpose. The grant is available for assistance 
of this character where the Board's general consent has been 
previously obtained to the local arrangements. 

Home Helps must, of course, be persons of suitable character. 
Where the confinement takes place at home they should under- 
take the necessary duties under the direction of the nurse or 
midwife in attendance. 

The duties of a Home Help would be the orduiary domestic 
duties usually undertaken by the mother, including cleaning, 
cooking, washing, care of children, mending and marketing. 
She should not undertake any work which properly belongs to 
the sphere of the trained nurse or midwife, nor assist at a con- 
finement unless a doctor or midwife is in attendance. 

It IB advisable to arrange for special training of Home Helps. 
This training may be given at Maternity Centres and Day 
Nurseries, and should include practical instruction in plain and 
invaUd cookery, food values and prices, laundry work, mending, 
infant care and hygiene. A course of one to three monthi, 
according to the previous experience of the woman, should be 

A scale of charges for the service of Home Helps should be 
made, but the charge may be remitted or reduced in individual 
cases where the circumstances justify it. 

Hospitals for Infants. 

29. This grant is now extended to hospital treatment of 
children up to five years of age, but save in exceptional cases 
it will be paid only to the Local Authority. It is not available 
in respect of the hospital treatment of ordinary infectious 
diseases, except ophthalmia neonatorum, but for the present 
the Board are prepared to give a grant towards the provision 
of hospital beds for epidemic diarrhoea, when these beds are 
provided elsewhere than at an Infant Welfare Centre. 



30. The conditions under which this grant will be paid were 
laid down in the Board's circular letter of 9th February last. 
The Board consider that schemes for the supply of food and milk 
should, where this provision is necessary, be undertaken by the 
authority carrying out the Maternity and Child Welfaj-e scheme. 
Where the Local Authority of a County District which is not 
canying out such a scheme considers that expectant and nursing 
mothers and young children in its district are not obtaining a 
proper supply of food and mUk, it sliould consult with the County 
Council as to the best means of supplying this need. 

A scale of charges should be laid down for the supply of 
food and milk, but the charge may be reduced or remitted in 
individual cases where the cii'cumstances justify it. 

Creches, etc. 

31. The Board's grant is available in respect of expenditure 
by Local Authorities on providing or aiding creches and day 
nurseries, and on placing children in the care of foster-mothers 
who are under supervision by the Medical Officer of Health. 
The grant is also available for aiding homes where children can 
remain through the night as well as the day, and is especially 
intended for the children of mothers who go out to work. A 
scale of charges should be fixed for these services, but the charge 
may be remitted or reduced in individual cases where the cir- 
cumstances justify the adoption of this course. 

Convalescent Homes. 

32. A stay in a convalescent home is specially important for 
recovery after certain cases of confinement and for some con- 
ditions in young children, especially after measles and whooping- 
cough. It is desirable, therefore, that Local Authorities 
should, either themselves or through a voluntary agency, arrange 
for beds in convalescent homes to be available as part of their 
schemes. As a general rule a grant will be paid to voluntary 
agencies providing convalescent homes only in respect of accom- 
modation provided in connection with a local authority's scheme 
and approved by the Local Authority and the Board. 

Homes for Children. 

33. The health of infants and young children who lack the 
rapport of a father often needs special attention, and it is on all 
groondf desirable that the motoer and child should be kept 


together in such cases, especially during the first year. It is 
notorious that the death-rate of illegitimate infants, the only 
infants in this category for whom separate statistics are pub- 
lished, is about twice the death-rate of legitimate infants. To 
some extent this is due to the difficulty experienced by their 
mothers in making a home for them. The mothers generally 
go out to work and leave their infants with foster-mothers. As 
a result of the war fewer suitable foster-mothers are prepared to 
take the children at a charge which their mothers can afford to 
pay. The Board have therefore obtained the Treasury assent to 
the extension of the grant to homes at which mothers and children 
can be kept together in certain cases, and to such other arrange- 
ments as the Board may approve for attending to the health of 
the children under consideration. In some cases it may be 
desirable to pay a good foster-mother to look after a child whose 
mother cannot afford the whole of its keep, or to assist the 
mother to stay at home to attend to the child. Any scheme 
for this purpose should be submitted for the Board's approval 
before expenditure is incurred on it if a grant is desired. 

Capital Expenditure. 

34. The grant is available in respect of the necessary adapta- 
tion and equipment of premises for the purpose of Centres, 
Creches, Homes and Hospitals. The erection of new premises 
for these purposes is impracticable at present, and with a view 
to keeping capital expenditure within the narrowest limits 
suitable existing accommodation '■ should, where possible, be 
obtained on lease rather than by purchase. All proposals for 
acquiring, adapting and equipping buildings for these purposes 
should be submitted to the Board before expenditure is incurred, 
with an estimate of the cost, if a grant is desired. 

Experimental Work. 

35. Mr. Hayes Fisher desires to encourage Local Authorities 
and Voluntary Agencies to undertake new work calculated to 
promote the health of mothers and children, and the Board will 
consider sympathetically any new proposal submitted to them 
under this heading. If a grant is desired, full particulars should 
be furnished of any such scheme and of its estimated cost before 
expenditure is incurred on it. 

Items excluded from Grant. 

36. The grant is not available in respect of the following 
items, which are frequently included in applications : — 

Payments to the Central ^Midwives Board, 



Payments to Registrars for returns of births. 

Certificates of deaths of midwives, 

Compensation to midwives for abstaining from work after 

contact with infection, 
Expenses of deputations. 
Rent of premises in the possession of the Local Authority or 

of the Education Committee, 
Any part of the salary of the Medical Officer of Health except 

an additional salary specially voted for Maternity and Cliild 

Welfare work, 
Clerical and other establishment expenses, except additional 

expendit\ire specifically necessitated by the scheme. 

Applications from Voluntary Societies. 

37. Grant is payable to voluntary societies on condition that 
the work is co-ordinated with the work of the Local Authority. 
It is convenient that applications from voluntary societies should 
be forwarded to the Board through the Local Authority with 
whose scheme they are co-ordinated. Where this is not done 
a copy of the application should be sent to the Local Authority 
at the same time as it is sent to the Board. 

Use of Ahortifacienta. 

38. A report was published by the Privy Council Office in 
1910 on the practice of medicine and surgery by unqualified 
persons. For the purpose of that Report the Board obtained 
some particulars from Medical Officers of Health which showed 
that the sale of drugs intended to procure abortion and practice 
by abortion-mongers was prevalent in many parts of the country. 
From information obtained by Medical Inspectors of the Board 
in connection with their inquiries into Maternity and Child 
Welfare work and from other material, the Board have reason 
to fear that these practices continue. One of the drugs most 
commonly employed for this purpose is diachylon, and on 27th 
April 1917, an Order in Council was made adding to the list of 
poisons for the purpose of Part I. of tlio Schedule of Poisons 

loEid in combination with oleic acid, or other highly fattcid 
acida, whether sold as diachylon or under any other designation 
(except machine spread plasters)". The Board would urge every 
Local Authority to bring this order to the notice of the druggists 
and of the practising midwives in their area, to explain to their 
Health Visitors and to the midwives the risks to life and health 
involved In the use of diachylon, and in every other way to do 


what they can to stop the traffic in abortifacients and the practice 
of abortion-mongers in their districts. 

This Circular will be placed on sale so that copies may shortly 
be obtained, either directly or through any bookseller, from 
H.M. Stationery Office at the following addresses : — Imperial 
House, Kingsway, London, W.C.2 ; and 28 Abingdon Street, 
London, S. W. 1 ; 37 Peter Street, Manchester ; and 1 St. An- 
drew's Crescent, Cardifif. 

I am. Sir, 
Your obedient Servant, 


The aerk to the Council. 

Regulations under which grants not exceeding one-half of 
approved net expenditure will be payable by the Local Govern- 
ment Board to Local Authorities and to Voluntary Agencies in 
respect of arrangements for attending to the health of expectant 
mothers and nursing mothers and of children under five years 
of age. 

\. The Local Government Board will pay grants during each 
financial year, commencing on 1st April, in respect of the fol- 
lowing services : — 

(1) The salaries and expenses of Inspectors of Midwives. 

(2) The salaries and expenses of Health Visitors and Nurses 
engaged in Maternity and Child Welfare work. 

(3) The provision of a midwife for necessitous women in con- 
finement and for areas which are insufficiently suppUed with 
this service. 

(4) The provision, for necessitous women, of a doctor for 
illness connected with pregnancy and for aid during the period 
of confinement for mother and child. 

(5) The expenses of a Centre, i.e., an institution providing any 
or all of the following activities : — medical supervision and 
advice for expectant and muring mothers, and for children 
under five years of age, and medical treatment at the Centre 
for cases needing it. 

(6) Arrangements for instruc|;ion in the general hygiene of 
maternity and childhood. 

(7) Hospital treatment provided or contracted for by Local 
Authorities for complicated cases of confinement or complica- 
tions arising after parturition, or for cases in which a woman 
to be confined suffers from illness or deformity, or for cases of 
women who, in the opinion of the Medical Officer of Health, 


cannot with safety be confined in their homes, or such other 
provision for securing proper conditions for the confinement 
of necessitous women as may be approved by the Medical 
Officer of Health. 

(8) Hospital treatment provided or contracted for by Local 
Authorities for children under five years of age found to need 
in-patient treatment. 

(9) The cost of food provided for expectant mothers and 
nursing mothers and for children under five years of age, 
where such provision is certified by the Medical Officer of the 
Centre or by the Medical Officer of Health to be necessary, 
and where the case is necessitous. 

(10) Expenses of creches and day nurseries and of other 
arrangements for attending to the health of children under 
five years of age whose mothers go out to work. 

(11) The provision of accommodation in convalescent homes 
for nursing mothers and for children under five years of age. 

(12) The provision of homes and other arrangements for 
attending to the health of children of widowed, deserted and 
unmarried mothers, imder five years of age. 

(13) Experimental work for the health of expectant and 
nursing mothers and of infants and children imder five years 
of age carried out by Local Authorities or volimtary agencies 
with the approval of the Board. 

(14) Contributions by the Local Authority to voluntary in- 
stitutions and agencies approved under the scheme. 

2. Grants will be paid to voluntary agencies aided by the 
Board on condition : — 

(1) That the work of the agency is approved by the Board 
and co-ordinated as far as practicable with the public health 
work of the Local Authority and the school medical service 
of the local education authority. 

(2) That the premises and work of the institution are subject 
to inspection by any of the Board's Officers or Inspectors. 

(3) That records of the work done by the agency are kept to 
the satisfaction of the Board. 

3. An application for a grant must be made on a form supplied 
by the Board. 

4. The Bf)ard may exclude any items of expenditure which 
in their opinion should bo deducted for the purpose of assessing 
the grant, and if any question arises as to tne interpretation oi 
these Regulations the decision of the Board shall bo final. 

6. The grant paid in each financial year will bo assessed on the 
basis of the exixmdituro incurred on tho service referred to in 
Article L in the preceding fmancial year, and will be, as a rule, 
At^thejrato^ofj^one-half of that expenditure whore the sorvicoB 


have been provided with the Board's approval and are carried 
on to their satisfaction. The Board may, at their discretion, 
reduce or withhold the grant. 

GIVEN under the Seal of the Local Government Board 

©this Ninth day of August, 1918. 



Circular No. 6 (M. & C. W. 11). 

County Councils {other than the 
London County Council), and 
Local Sanitary Authorities. 


Ministry of Health, 
Whitehall, S.W.I, 
15th July 1919. 


1. I am directed by the Ministry of Health to enclose forms 
on which application may be made for a grant in aid of expendi- 
ture on Maternity and Child Welfare dming the current year. 
^2. The Treasury have sanctioned an amendment of Article 5 
of the Regulations of 9th August 1918, to enable grant to be 
paid on account in respect of expenditure on Maternity and 
Child Welfare. The Article now reads as follows : — 
• ? ." The grant paid in each financial year will be, as a rule, at 
ij the rate of one-half of the expenditure on the services referred 
"■t to in Article 1, where the services have been provided with 
^^ the Ministry's approval and are carried on to their satisfaction. 
j^tThe Ministry may, at their discretion, reduce or withhold the 
& grant. 

pin the present year the Ministry will pay local authorities a 
grant on account amounting to 40 per cent, of the estimated 
expenditure of the current year, with the addition of the sum 
necessary to make up the grant for the preceding year to half 
the ascertained expenditure of that year. 

3. The grant is available in respect of expenditure on adapta- 
tion and equipment of premises if paid out of revenue. The 
Ministry are now able to entertain applications from local 
authorities for sanction to loans for the pmchase and erection 
of premises urgently needed for pubUc health purposes, but 


before sanctioning a loan for the erection of a building for 
Maternity and Child Welfare, they will require to be satisfied 
that no existing building or disused roiUtary establishment is 
available and could properly be utilised. Where a loan is 
sanctioned, grant will be paid on the annual charge. 

4. The nursing of cases of poliomyeUtis in yoimg children may 
now be included amongst the matters in respect of which a grant 
is payable. 

5. The Ministry desire to explain that the grant is not avail- 
able in respect of the following items, which are mistakenly 
included in many of the applications received by the Ministry : — 

Payments to the Central Midwives Board, 

Certificates of deaths of midmves, 

Compensation to midwives for abstaining from work after 

contact with infection, 
Expenses of deputations. 
Rent of premises in the possession of the Local Authority or 

of the Education Committee. 
Any part of the salary of the Medical Officer of Health except 

an additional salary specially voted for Maternity and Child 

Welfare work, 
, Clerical and other establishment expenses, except additional 

expenditure specifically necessitated by the scheme ; 
and the following incidental expenditure incurred in connection 
with the activities of National Baby Week celebrations : — 
Prizes and ceilificates, 
Payment of nurses for organising baby shows and classifying 

Payments to doctors and nurses for judging babies. 

6. In future, grant will be payable for hospital accommoda- 
tion for measles and whooping-cough occurring in children under 
five years of age, either permanent or temporary in character, 
provided either at a hospital for infectious diseases or in a 
separate institution. If this accommodation is provided at a 
local authority's hospital for infectious diseases it must be so 
arranged as not to interfere with the accommodation for tho 
other infectious diseases which are usually admitted to hospital. 

7. Grant will in future be payable in respect of payments to 
Registrars for Returns of unnotified births. 

1 am, 8ir, 

Your obedient Servant, 

The Clerk to the Council. 



Circular 4. — Local Authorities (M. & C.W. 10). 

To the Clerk of the Local Authority. 

MiNiSTBY OF Health, 

Whitehall, S.W.I. 

The Teatning of Health Visitors, Especially for Mater- 
nity AND Child Welfare Work. 

1. The Minister of Health is desirous of inviting the attention 
of Local Authorities and others concerned in maternity, child 
welfare and other departments of pubUc health to the im- 
portant Regulations just made by the Board of Education, 
after consultation with this Ministry, for the payment, from the 
Board, of grants in aid of the training of women to become 
Health Visitors. 

2. The functions of Health Visitors have become widely 
known and appreciated in the last ten years ; but it may tend 
to the better understanding of the purpose of the now projected 
developments, both in the new Regulations of the Board of 
Education and in the consequent higher standards to be looked 
for by this Ministry in local work, to recall here, briefly, the 
history of their origin and past development. It was the Lon- 
don County Council (General Powers) Act, 1908, which first em- 
powered sanitary authorities in London to appoint suitable women 
to be known as Health Visitors whose duties would include (a) 
giving advice on the proper nurture, care, and management of 
young children, (6) the promotion of cleanliness as the basis of 
health, and (c) such other analogous duties as might be 
assigned to them. The Local Government Board were author- 
ised by the Statute to make Regulations prescribing the quahfi- 
cations, duties, salary, mode of appointment and tenure of office 



of Health Visitors appointed under the Act, and it was stipulated 
that no appointment should be made otherwise than in accord- 
ance with such Regulations. 

3. Although at the time of the passing of the Act a number of 
women known as Health Visitors had already been appointed 
to advise mothers as to the care of their infants, the Board 
had not then had sufficient experience of the scope of their work, 
and of the qualifications necessary for it, to justify them at that 
time in estabUshing or requiring a special course of training for 
the Health Visitors who were to be appointed under the Act. 
The qualifications which the Local Government Board then 
prescribed in their Order were as follows : — 

(a) a medical degree, or 

(b) the full training of a nurse, or 

(c) the certificate of the Central Midwives Board, or 

{d) some training in nursing and the Health Vi'iitor's certifi- 
cate of a Society approved by the Board, or 
(e) the previous discharge of duties of a similar character in 
the service of a Local Authority. 

4. At that period, and in subsequent years, great impetus 
was given to the appointment of Health Visitors by the Notifi- 
cation of Births Act, 1907 (which was made compulsory by the 
Extension Act of 1915), and by the institution of the Exchequer 
grants in aid of the local provision of arrangements for maternity 
and child welfare in 1914. And it may now be said that, although 
at the present time the number of Health Visitors is still seriously 
insufficient for the needs of the population, some provision is 
made for health visiting in most parts of England and Wales. 

6. The standard of efficiency of this health visiting, however, 
varies greatly. Outside London no qualifications have hitherto 
been prescribed for Health Visitors. But the Local Govern- 
ment Board have constantly recommended that the women 
appointed to undertake this work by Local Authorities should 
possess one or more of the qualifications prescribed by the London 
Order, with the addition of the certificate of a Sanitary Inspector ; 
and investigation has shown that at the present time nearly all 
of the Health Visitors at work in England and Wales possess one 
or more of these various qualifications ; but this, of course, 
especially taken in conjunction with the inaxioquacy of the num- 
bers, is not sufficient to secure such a standard of work generally 
as the nation has a right both to expect and to receive nowadays 
in this important sphere of public welfare. 

6. The Act of 1908 quoted above, and the lioard's Order made 
under it, permitted the duties of Health Visitors to cover a 
wide field. In practice, however, their special function in 
London has usually been maternity and child welfare work with 


particular regard to the care of infants. The value of the work 
which they have done in assisting the campaign against infant 
mortality has been widely recognised. In addition to the 
regular visiting of infants in their homes, they are now frequently 
employed to assist in supervising, under medical control, the 
health of children under school age, to attend Maternity and 
Child Welfare Centres, and to investigate the circumstances in 
cases of still- births and the deaths of young children. The 
varied nature of their duties requires, it is obvious, a carefully 
devised course of professional training. But it has been found 
in practice that tbe qualificatione set out above, though ad- 
mittedly comprising the most useful existing qualifications for 
the discharge of these duties, include certain subjects not directly 
relevant and omit certain subjects on which it is eminently 
desu'able that Health Visitors should be well informed. 

7. It may be said, in this connection, that from the beginning 
it has been recognised that, when circumstances permitted, it 
would be necessary that a special course of training for Health 
Visitors generally should be prescribed. Now that the time 
seems opportune for the institution of such a course, the Ministry 
of Health have welcomed, and have been glad to co-operate in, 
the action of the Board of Education, as the Department re- 
sponsible to Parliament for the provision of education and 
training, in framing regulations defining the terms and conditions 
which should govern the disbursement of Exchequer grants in 
aid of the provision of efficient courses of training for future 
Health Visitors. 

8. It will be observed that the Board of Education Regulations 
(copy enclosed) which have been framed in consultation with the 
Ministry of Health, and with direct regard to the duties of Health 
Visitors as prescribed by the Ministry of Health under the Acts 
above referred to, make provision (a) for a course of two years for 
candidates without previous training, and (6) for a course of one 
year in the case of fully trained nurses, of women with experience 
of health visiting, or of those possessing a University Degree 
or its academical equivalent — assuming in each case that the 
individual possesses sufficient general knowledge or experience 
to profit by such a course. 

9. In view of the great importance of securing the appointment 
of properly trained persons as Health Visitors, and of the en- 
larged opportunities that will arise under the developments just 
described, the Ministry of Health have now decided that, in cases 
requiring Government sanction and grant, the Ministry will 
require that all women appointed for the first time as Health 
Visitors on and after a date of which due notice will be given 
must have obtained the certificate desci'ibed in these Regulations 


of the Board of Education, with or without other qualifications. 
Women mtending to enter the profession in the future are there- 
fore advised to take a course of training at one of the institutions 
recognised by the Board of Education, who will announce a list 
of such institutions. It is to be noted that these reqmi-ements 
by the Ministry as to candidates having been trained in a course 
under these Regulations wiU apply only to salaried Health 
Visitors. At many Maternity and Child Welfare Centres (both 
municipal and voluntary) mipaid workers are engaged, who, 
where they undertake the regular discharge of definite duties, 
render valuable assistance to the work of the Centre. These 
workers should be experienced and competent, and some training 
is desirable for them also ; but they need not necessarily possess 
certificates given after a formal course of training. 

10. It is further to be understood that, until such time as the 
Ministry consider that there have become available a sufficient 
number of candidates who have completed a course recognised 
under the Training Regulations, women who are now acting as 
Health Visitors, and women who may be appomted during the 
intervening period as Health Visitors, will not be required to have 
taken either the fuU or the shortened course of training as a 
condition of repayment of half theu' salary from the Maternity 
and Child Welfare grant. At the same time, it is hoped that 
local authorities will afford facilities to such Health Visitors to 
take an approved course of training where they desire to do so, 
and where the Medical Officer of Health is of opinion that it 
would increase their efficiency. The Ministry of Health would 
also recommend that Local Authorities making new appoint- 
ments of Health Visitors from the present time, until women 
qualified under the new Regulations are available, should always 
endeavour to secure more than one of the qualifications already 
prescribed for London and recommended for the rest of the 
country by the Local Government Board, as set out in the third 
and fifth paragraphs of this Circular. For it should now usually 
be possible to ol>tain women possessing more than one of these 
qualifications ; and the Ministry will not, as a rule, be prepared, 
after a date of which due notice will be given, to pay grants in 
respect of the salary of any newly appointed Health Visitor who 
has only the qualification of a midwiie or of a Sanitary Inspector, 
unless she has previously rendered satisfactory service as a Health 
Visitor in another District. 

1 1. While the Ministry of Health will accept the standard of 
training laid down by these Training Regulations as a sufficient 
qualification both for Health Visitors and for Tuberculosis 
Visitors and Nurses, it is recognised that some local authorities 
may desire further qualifications in the women they appoint in 


those capacities, especially where they are called upon to perform 
additional duties to those enumerated above. The following 
observations may be useful regarding such additional duties. 

12. It is often urged that, generally speaking, and especially 
in country districts, the Health Visitor should discharge all the 
duties akin to those of health visiting in the " district " assigned 
to her, on the grounds that such an arrangement reduces the size 
of the district allotted, and tends to minimise the time spent in 
travelling. It also reduces the number of inspectors who may 
visit a house for various purposes, a matter of considerable 
importance. This principle, however, needs to be adopted and 
applied with circumspection and careful regard to local circum- 
stances, and to the conditions requisite for attaining a sufficiently 
high standard of efficiency, especially in centres of congested 
population. This is especially true in respect of work in con- 
nection with Tuberculosis and Mental Deficiency, which are the 
other functions most often allotted to Health Visitors in several 
areas in England and Wales. 

13. Many Health Visitor? at present act as Assistant Inspectors 
of Midwives under the Medical Officer of Health or the Assistant 
Medical Officer of Health. The Ministry of Health consider 
that the inspection of midwives, including routine as well as 
special inspections, should be carried out by a medical practi- 
tioner, preferably a medical woman ; and it is urged that all 
supervising authorities under the Midwives Act who have not 
already done so, should as soon as possible, appoint on their 
staff a woman Medical Officer to supervise maternity and child 
welfare work and to inspect midwives under the direction of the 
Medical Officer of Health. In cases where it is unavoidable that 
a non-medical woman should take part in the inspection of mid- 
wives it is essential that she should not only possess the certificate 
of the Central Midwives Board, but should have had substantial 
experience as a practising midwife. 

14. The visiting of expectant mothers before confinement, 
and of infants duruig the first ten days after birth, is at present 
undertaken in some areas by Health Visitors. The Ministry of 
Health are of opinion that this work should be assigned to the 
midwife (where a midwife has been engaged by the mother) 
wherever this can be done consistently with the efficient discharge 
of the important duties involved. And it is hoped that this 
arrangement will be greatly facilitated in course of time by the 
improvement to be expected in the efficiency of midwifery 
practice arising from the new grants and regulations for the 
training of midwives that wU be shortly issued by the Board of 
Education in concert with this Ministry, 

15. In many rural areas it is the custom to select the District 


Nurses for appointment as Health Visitors by County Councils 
organising maternity and child welfare schemes. There is no 
doubt much to be said for this arrangement in rural areas, 
but in its operation care must be taken to secure the necessary 
conditions for its efficiency. For the present, although the 
Ministiy of Health will not require as a condition of grant that 
such District Nurses should have undergone the course of train- 
ing prescribed by the Board of Education Regulations for the 
training of Health Visitors, it is strongly recommended that 
County Councils should arrange that all District Nurses who are 
to act as Health Visitors should be given the opportimity of 
practical training for not less tjian three months under an ex- 
perienced Health Visitor, and should be required, generally 
speaking, to take advantage of such opportunities so soon as they 
are provided. 

16. As a general rule the Ministry of Health do not consider 
it desirable that Health Visitors in populous districts should xmder- 
take either midwifery or district nursing. It is better that 
trained midwifes should be appointed or subsidised for the former 
purpose, and that separate officers should be appointed in these 
areas as District Nurses, or arrangements made with District 
Nursing Associations for the nursing services necessary under 
Maternity and Child Welfare Schemes. 

17. Some Health Visitors who possess the requisite qualifi- 
cation have been appointed as Sanitary Inspectors of Nuisances, 
or as Assistants in those capacities, to discharge the duties of 
such officers which are usually assigned to a woman. The 
Ministry of Health will bo prepared to approve this arrangement 
where it is found convenient ; but they consider it undesirable 
that a Health Visitor acting in this capacity should exercise the 
functions of a Sanitary Inspector or Inspector of Nuisances in 
respect of the serving of notices and the conduct of prosecutions 
for sanitary defects discovered in the course of her visits as a 
Health Visitor. 

18. In conclusion Dr. Addison desires, as Minister of Health, 
strongly to emphasise the necessity of securing that so far as 
practicable only those women should be appointed to salaried 
posts for the important functions comprised in health visiting 
who possess a good general education followed by an efficient 
course of special training in an institution approved by the 
Board of Education under the new training Kcgulations. It 
must be remembered that the amount of the grants now being 
paid annually from the MiniHtry of Health to Local Authorities in 
aid of their expenditure on health visiting and other elements of 
their Maternity and Child Welfare Schemes is rapidly increasing, 
and that Parliament is in fact 2)roviding virtually ono-half of 


what is now spent locally in this field of health work. It is thus 
incumbent upon the Ministry of Health, as responsible to 
Parliament for the proper expenditiu-e of these large and increas- 
ing Exchequer subsidies, to take all reasonable steps to secure the 
adoption of every practicable measure for raising the standard 
of much of the existing work, which has been in some places 
inevitably of a somewhat indifferent character during the early 
years of its development. Such a condition of things will be 
inexcusable so soon as the conditions of working are improved, 
and the supply of properly trained women for these purposes is 
increased, in virtue of the further pecuniary assistance from 
Parhament to be provided under the new Regulations of the 
Board of Education herein described. It is with this object 
that the Ministry are issuing this Circular to Local Authorities, 
in the assurance that it will receive sympathetic and appreciative 
response from all these Authorities and their staffs, and also from 
the great band of voluntary workers who devote themselves so 
earnestly to the welfare of the mothers and children of this 
country ; so that by hearty co-operation between these various 
bodies there may be secured throughout the country a gradual 
but steady improvement in the effectiveness of all work attempted 
in this extremely important sphere of pubUc health. 
I have the honour to be, 
Your obedient servant, 

Ministry of Health, 
July Uth, 1919. 



SERY SCHOOLS, 1919 (including Regulations for 
Payment of Grant in respect of those Schools), 
made by the board of education under section 44 
OF THE Education Act, 1918 (8 & 9 Geo. 5, c. 39). 




1. Section 19 of the Education Act, 1918, which came into 
operation on the 8th August 1918, reada as follows : — 

"(1) The powers of Local Education Authorities for the 
purposes of Part III. of the Education Act, 1902, shall include 
power to make arrangements for — 

" (a) supplying or aiding the supply of nursery schools (which 
expression shall include nuraery classes) for children over two 
and under five years of age, or such later age aa may be approved 
by the Board of Education, whose attendance at such a school 
is necessary or desirable for their healthy physical and mental 
development ; and 

" (6) attending to the health, nourishment and physical 
welfare of children attending nursery schools." 

" (2) Notwithstanding the provisions of any Act of Parliament 
the Board of Education may, out of moneys provided by Parlia- 
ment, pay grants in aid of nursery schools, provided that such 
grants shall not bo paid in respect of any such school unless it 
w open to inspection by the local education authoiity, and unless 
that authority are enabled to appoint reprosnntativos on the body 
of managers to the extent of at least one-third of the total number 
of managers, and before recognising any nursery school the 
Board shall consult the local education authority. 



2. Aims of the Nursery School. — ^A Nursery School or Class 
is an institution providing for the care and training of young 
children aged from two to five years, whose attendance at such 
a day school is necessary or desirable for their healthy physical 
and mental development. It has therefore a two-fold function : 
first, the close personal care and medical supervision of the 
individual child, involving provision for its comfort, rest and 
suitable nourishment ; and secondly, definite training — 
bodily, mental and social — involving the cultivation of good 
habits in the widest sense, under the guidance and oversight 
of a skilled and intelUgent teacher, and the orderly association 
of children of various ages in common games and occupations. 

The child is first and foremost a growing organism : the 
nursery school will, on the one hand, Uberate the growing child 
from the influences of environment and constitution which 
retard, confine, and distort its growth, and, on the other hand, 
will stimulate and direct its growth. It is much more than a 
place for " minding " children. The need of nursery schools is 
greatest in the more congested areas of the large towns. The 
influences which an adequate supply of efficiently managed 
nursery schools could exercise upon both children and parents in 
such areas can hardly be overestimated. 

PhysioajL Cabb. 

4. General Hygiene. — The provisions of the Act emphasise 
the need for attending to the health, nourishment and phjrsical 
welfare of the children. The improvement of their health is 
indeed one of the main benefits which attendance at a good nur- 
sery school should bring with it. In a broad sense, physical 
welfare will always be in view, and there is hardly any Umit to 
the beneficial influence of a nursery school on this side of its 
activities. Physical care includes not only opportunities for 
rest, exercise and physical development, but the provision of 
a healthy school environment and the inculcation of hygienic 
habits of life, of which the thorough practice of personal clean- 
liness is an obvious example. Equally important is suitable 
provision for the cliildren's food. Meals, including a mid-morning 
lunch and midday dinner, should as a rule be taken at the school, 
and it may be desirable, or even necessary, in some cases, to 
provide the children also with breakfast and tea. The arrange- 
ments for meals will need careful supervision. The dietary 
should bo suitable and sufficient. The children should spend a 
definite part of the day in rest and sleep. Neither the exact 
time for the rest nor its length need here be prescribed, but it 
is important that the period should be the same each day ; the 


teacher will herself decide, according to circumstances, what 
occupations should precede or follow the period of rest. The 
rest should be taken on low stretchers, easily set up and stored 
away, or on clean mats, and should mean lying down and not 

5. It will also be necessary to provide training directed to 
promoting the healthy development of the body. Appropriate 
physical training is as indispensable for younger as for older 
children. In addition to very simple organised exercises, they 
should be allowed and encouraged to move about freely, to use 
their Umbs as their natural energy prompts, and to play the cus- 
tomary simple group games, with running, jumping and marching. 
They should be taught to Ijreathe correctly and naturally ; and 
all this should take place in clean and airy surroundings. The 
importance of facilities for out-of-door hfe cannot be overesti- 
mated. Whether in a garden (under more fortunate circum- 
stances) or on a roof or other playground, kept clean and screened 
from too much wind, from wet, and from the sun in the height 
of summer, the children in nursery schools should spend a con- 
siderable time in the open air. Nor need the use of the outdoor 
space be confined to play in the form of free bodily exercise. 
In warm weather especially the chairs, tables and stretchers 
can be carried outside, and most of the day's occupations be 
conducted in the open air. 

6. Medical Supervision. — As is intimated in Article 4 of the 
Regulations, a nursery school should stand in close relation to 
the School Medical Service. Whether maintained by the Ijocal 
Education Authority or by a voluntary body, the school should 
be under the supervision of the School Medical Officer. In the 
case of a voluntary nursery school it may not always be con- 
venient for the School Medical Officer to undertake the whole of 
the medical inspection, but even in such a case the medical prac- 
titioner employed for this purpose should be in touch with the 
School Medical Officer, who should visit the school from time 
to time. The medical practitioner selected should preferably live 
near the school, to be readily available in case of emergency. 

7. Medical supervision of nursery schools is desirable for four 
reaaons: — 

(a) To prevent the admission of physically unsuitable children. 
(6) To prevent, as far as possible, the development of physical 
defects or ailments, and to ensure prom2)t treatment where 

(c) To avoid, as far as possible, the spread of infectious diseases 
such as measles and whooping-cough by providing oppor- 
tunities for early diagnosis and the adoption of prompt pre- 
rentive measures. 


(d) To create and develop healthy habits of life, and the 

avoidance of injury to the senses. 

Among the children who desire admission there may be some 
who are physically unfit to attend even a nursery school. In 
other cases it may be desirable to retain children at the school 
on the grounds of health for a longer period than usual before 
sending them to the Pubhc Elementary School. 

Various physical habits frequently observed among httle 
children, such as mouth- breathing, squint, near distance eye 
work, etc., should be detected at the earliest opportunity, and 
arrangements made for their careful correction. One reason 
for the provision of Nursery Schools is indeed to reduce the large 
numbers of preventable defects now observed in entrants to the 
Pubhc Elementary School, and the associated educational 
handicap and resulting incapacity. For several years past the 
degree and character of defects prevalent among childien on 
their first admission to the elementary schools have revealed a 
widespread measure of low physical condition in children under 
five, not a little of which might have been prevented if it had 
been properly dealt with between two and five years of age. 

8. Medical Inspection and Trealment. — Each child should be 
medically inspected according to a prescribed schedule as soon 
as possible after admission, and should be seen, though not 
necessarily examined, by the doctor not less than once a term. 
Ailing children may require more frequent inspection. The 
School Nurse may be employed to assist in the periodical 
medical examination of the children and in following up the 
children found to be defective. She may also pay daily visits 
to the school to make a " health inspection," take temperatures, 
if and when necessary, and deal with minor ailments. In many 
cases, however, it would be more satisfactory that the Superin- 
tendent or another member of the staff who possesses the re- 
quisite qualifications should discharge some or all of these 
duties. She should weigh and measure the children at least at 
the beguming and end of each term (preferably once a month), 
and she should have a definite responsibility for the hygiene of 
the school, including the cleanliness of the childi-en and the 
suitability of their clothing and footgear. 

9. The facilities for treatment and the arrangements for 
" following up " provided for children in attendance at public 
elementary schools should be available for children in nursery 
schools. For example, a child suffering from squint, nasal 
obstruction or discharging ears, should be referred to the School 
Clinic for advice and, if necessary, treatment. Minor ailments, 
e.g., cuts, sores, chilblains, should be dealt with at the school 
itself. Particular attention should be paid to correct breathing, 



and the school staff should be trained to observe sUght departures 
from the normal, which are the early indications of defects of 
sight, hearing, or nutrition. They should refer such cases to 
the Medical Officer. 

Records of physical conditions, defects and treatment, should 
be kept on schedules adapted from those in use at the public 
elementary school, and should be transferred when the child 
enters the ordinary school. If the child has previously attended 
an Infant Welfare Centre a copy of its record should be obtained. 

10. Epidemic Disease. — The prevention of epidemic disease is 
particularly important where numbers of susceptible children 
under five years of age are in frequent and close contact. The 
younger the children the greater is the mortality from such 
diseases as measles and whooping-cough. Ninety per cent, of 
the deaths from measles and its complications occur under the 
age of five years. If the attack of measles, for instance, can be 
postponed beyond early childhood the illness is likely to be less 
severe, and there is less habiUty to dangerous complications or 
after-effects, such as pneumonia or the development of tuber- 
culosis. Children known to have suffered recently from 
infectious disease should receive special care and supervision 
in order to prevent the development of after-effects, such as 
tuberculosis. Epidemics can be prevented to a considerable 
extent — 

(1) by daily inspection by a competent observer of each child 
as it enters the school ; 

(2) by the strict adherence of the school staff to rules drawn 
up for their guidance (e.g., in regard to exclusion of " con- 
tacts " or of cases of infectious disease at an early or incipient 
stage) ; 

(3) by exclusion of cases of " colds " or suspects ; 

(4) by the cleanliness and hygiene of each child ; 

(5) by the management of the school on open-air lines. 

The School Medical Officer should be responsible for rules 
designed to prevent the transmission of infection, and for a 
general oversight of the arrangements. The necessary daily 
mspections should be carried out either by a qualified nurse or 
by a senior member of the staff if she possesses suitable and 
sufficient experience. It should not be delegated to junior or 
inexperienced members of the staff. 

Suspicious cases should bo isolated pending medical advice. 
Arrangements for the examination of suspected cases of infectious 
disease should bo made by the School Medical Officer in conjunc- 
tion with the Medical Officer of Health (to whom notification of 
infectious cases must be sent). It may prove convenient to 
obtain a local doctor to examine such chiJdron. In any case 


much more effective and systematic steps should be taken 
through the Nursery School in regard to the diagnosis and 
following up of measles, etc., than have been practicable in 
connection with the ordinary Infant School. It is, perhaps, 
desirable to add that no scheme of Nursery Schools will receive 
the Board's approval until and unless proper safeguards have 
been secured. 

^Mental and Social Trahono. 

11. It would, however, be a mistake to assume that healthy 
physical development is the sole concern of a Nursery School, 
and that the growth of the mind can safely be neglected. The 
school should provide specific training on this side as well as on 
the physical. It has much to do in the way of preparing the 
children to begin the work of the Elementary School with well- 
formed habits, with minds alert and eager to learn and unspoiled 
by premature attempts to teach what is unsuitable. Formal 
work in Reading, Writing, and Arithmetic should have no place 
at all in the Nursery School. The best preparation for the 
three R's is a training in speech and language. The children 
should be taught to use their voices naturally, without harshness, 
and to articulate freely and correctly. They should be encour- 
aged to ask questions, to understand and act upon what is said 
to them, to talk freely on their own Utile concerns, to say simple 
rhymes and poems, and to sing together. Music and singing 
will help in the training of speech, and by stories told to groups 
of children they will learn something of the pronunciation and 
meaning of words. The skilful teacher will know how to entice 
even the shyest cliild into talking. The picture books and toys, 
with which a Nursery School should be well stocked, the garden 
and the pets that may be kept, will furnish material enough for 
talking. One of the objects of training in speech is to give the 
child, often brought up in narrow surroundings, ideas as well as 
words — things, in short, to talk about. In Wales it is desirable 
that the language of the Nursery School should be the language 
of the children's home. 

12. Development of Motor and Sensory Experience. — A be- 
ginning may be made in directing that motor and sensory ex- 
perience of the child which is vital to its harmonious development. 
For though manual work as ordinarily understood is more suit- 
able for children over the age of five years, its broad principles 
may be introduced in the Nursery School. The child learns 
through action ; indeed, true muscular culture is brain culture ; 
and the early spontaneous movements of the child are of great 
importance as stimulative to the brain centres. Certain forms 


of handwork and simple physical exercises — walking, hopping, 
skipjjing, marching, running, and arm exercise — are valuable 
and lead out the child's motor powers. It should be remembered 
that handwork should be so devised as to pro\ide (a) for an 
appropriate degree of repetition, (6) for sufficient variety in form 
and nature, and (c) for tasks which can be completed in them- 
selves at once or in one or at most two lessons. Above all, the 
handwork and other occupations of the children in the Nursery 
School should have a piu-pose. The interest of yoimg children 
is in occupations which have meaning, which do something, 
and which are followed by results. They like to handle things, and 
push them about, to make, create, and use ,- to build towers 
and destroy them ; to collect and have the sense of ownership ; 
to come into contact with and control other forms of existence 
than their own. All these early natural aspirations should be 
cultivated, developed and directed in the Nursery School. 

13. Another principal aim will be what is sometimes called 
*' sense-training." The purpose of such training is not primarily 
to cultivate the ability to make minute discriminations between 
different sounds, textures, weights, or even colours, an ability 
which may be speedily lost if it is not constantly utihsed. It is 
rather, as regards sight, to teach the child to notice broad rather 
than fine differences in colour, form and size ; as regards hearing, 
to listen with attention, to respond to quiet questions and 
commands, to distinguish different sounds, and to develop a 
taste for pleasant sounds instead of noise ; in touch, to enable the 
child to interpret shape, size and texture through his fingers, 
and to use his hands and fingers for manipulation, such as the 
careful carrying of utensils and the gentle treatment of flowers. 
The child may also learn to distinguish between the scents of 
various articles and to judge of weight. In the course of these 
activities the children will add indefinitely to their stock of ideas 
and of words with which to express them. Closely associated 
with this aspect of education is the training in balance and 
equilibrium and in easy and graceful movements in walking ; 
while a sense of rhythm may be fostered through music and 
dancing. Bad habits both in sitting and in moving, ungainly 
waddling and cramped postures, should bo patiently corrected. 

14. Social Training. — Much of the training above suggested 
will, no doubt, have to bo accomplished with individuals taken 
alono or in small numbers together. But the Nursery School 
should afford scope also for social training ; thus the children 
should bo trained to cat properly and in general " to behave 
mannerly at table." They should assist in laying and clearing 
the table, and perhaps in some simple washing up. In the same 
way they can b« enlisted in the service of Keeping the rooms 


tidy, and be taught to put away their playthings in the proper 
place. If it is rightly conducted, the whole trend of the Nursery 
School will be to accustom the children to attend to themselves, 
to fasten and unfasten clothes and boots without haste or care- 
lessness, to keep themselves as well as their surroundings tidy 
and neat, and to take a pride in helping themselves and one 
another. Nor need it be feared that such a school will present 
the over-clean appearance of a too-strictly regulated institution. 
Again, even young children can learn to share in games, to 
play together with common toys, sometimes the older with the 
younger, and sometimes the older by themselves. The im- 
portance of arousing a spirit of co-operation and of mutual help 
need not be here elaborated. This spirit is not inconsistent 
with the cultivation of a sense of ownership and of pride of pos- 
session ; if each child not only has access to the common cup- 
board or shelves of playthings, but has a few of his own to use 
or to lend, or is given a plant to tend or duties which he alone is 
to perform, his personal interest in the school will be increased. 
It will probably be found advisable to let occasions of collective 
work, in stories, games or music, succeed periods when children 
are left to play as then- own choice dictates. Nothing pleases 
the average child better, after he has pla5'ed alone with toys 
and his interest is exhausted, than to join his fellows in Ustening 
to a story, in singing or in a game. It is perhaps hardly necessary 
to say that a " Time-Table " is altogether out of place in these 
matters, and that the finish of a period of collective work should 
be determined when the children have obviously had enough. 
Specified times must of necessity be set for the beginning and end 
of the session, for meals, and for rest ; but nothing more than 
these need be settled beforehand. 

16. Definite and clearly conceived as the training in the Nur- 
sery School should be, it does not imply any formal classification. 
Strict adherence to an age basis in distributing children in classes 
should be avoided, for, as has already been said, one of the chief 
elements in the training of the children is the cultivation of the 
spirit of common play and mutual help, such as is found in every 
well-conducted household, and not least in families which do 
not contain nurseries. It is a good rather than a bad thing that 
the group of children under one teacher or assistant should 
consist of children of different ages. The child of two or three 
will not, of course, be able to join in all that children of four or 
five can do, but he will watch with interest and delight. Nor 
will he always follow the story to which the older ones will 
listen with eagerness, but he can be set free to wander and play 
on his own account. Older childien, too, even if they have games 
and pursuits of their own, do not lose the power of enjoying the 


simpler pursuits of their younger brothers and sisters. They 
will often become interested in the play of the younger children 
and will be delighted to help and amuse them. 

Administeativb Arrangements. 

E9'16. Site, Premises, and Equipment. — It is important that the 
site should be easy of access to the children's homes. It may, 
indeed, be argued that the healthy physical development of the 
children in large centres of population would best be secured by 
placing the school in some open locality away from congested 
areas, but the balance of advantage is in favour of the school 
being in close proximity to the children's homes. There are 
grave difficulties in the way of conveying children to a distant 
school ; they could not ordinarily be accompanied by their 
elder brothers or sisters ; mothers would lose touch with the 
school and the staff, and would be disinclined to allow their 
younger children to attend ; and, in case of illness, serious 
difficulties might arise. For these reasons the Board would not, 
as a rule, be prepared to recognise a nursery school that was not 
situated within convenient walking distance of the children's 
homes. The necessity of crossing dangerous thoroughfares must, 
of course, be avoided. 

17. In the choice of premises the following main considerations 
should be kept in view : — 

(a) Some outdoor space in the form of a garden or yard is 
essential unless the school practically adjoins a park or other 
open space which can be used instead. Whenever possible, 
JVench windows opening direct from the rooms on to a verandah 
or the garden or yard should be arranged. In some cases it 
may be possible to provide a roof playground if outdoor space 
cannot be obtained. 

!"•" (6) The rooms should be arranged with a view to an all-day 
occupation ; in each of the principal rooms not less than 12 to 
15 square feet of floor space per child should be provided. Light 
and ventilation should receive special attention. A south or 
south-east asjject is desirable and open-air conditions should be 
aimed at throughout. 

(c) The necessary accommodation should be available for the 
daily inspection of the children, for the preparation and servnoe 
of meals (though a separate dining-room will not usually be 
needed), and for suitable arrangements for rest and sleep. 

{(I) Ample provision of cloakroom, lavatory basins, bathroom 
and sanitary conveniences, should bo regarded as particularly 
important. The arrangements should be as simple and econo- 
mical M poMiblo, designed to permit of convenient super- 


vision of very young children. Assuming a constant supply 
of hot water, one bath may suffice for, say, 50 children. For 
about the same number of children four sanitary conveniences 
should suffice, though in a larger school separate arrangements 
may be needed for boys of five or six years of age. 

The necessary arrangements may be summarised as follows : — 

Lavatory. — A row of basins ; if fixed they should be sufficiently 
low for the children to reach. Enamelled basins on a wooden 
bench answer satisfactorily if a low sink is provided for emptying. 
A separate numbered towel for each child, a tooth-brush and 
mug, and a comb are desirable. 

Bathroom. — A small slipper bath raised above the ground is 
probably the most convenient. 

Sanitary Conveniences should usually be provided within the 
building, or in any case connected with it by a covered way. 
They must be so arranged as to be easily supervised. Low 
washdown conveniences are suitable. They should be partially 
screened, so that the cliildren cannot see one another, though the 
assistant can easily supervise them all. 

Cloakroom. — It should be possible to dry wet clothing and 
shoes. Each child should have a separate numbered peg. 
Washable overalls and slippers may be provided, and are almost 
essential in wet weather. 

19. The equipment of the children's rooms should be simple, 
and should include Ught tables and chairs (of appropriate size, 
weight, and form), washable rugs, stretcher beds, educational 
apparatus, and toys. 

20. The Size of a Nursery School. — It is obvious that a nursery 
school should be small and homelike : it should not be compar- 
able in point of size to most departments of urban public elemen- 
tary schools. About 40 children is probably the ideal number 
for a nm:sery school, but it may sometimes be necessary to pro- 
vide for more than 40 if the needs of a district are to be at all 
adequately met. The Board will therefore not refuse to consider 
proposals for a nursery school providing for as many as 80 to 
100 children ; but in no case should the number exceed 100. 

21. The Age of Admission and Leaving. — Under Article I (6) 
of the Regulations a child may not be admitted before the age 
of two years ; but it is desirable that children should beg:in to 
attend the Nursery School soon after that age ; good habits 
are more easily formed and many ailments to which children 
•are Uable are more amenable to treatment at an early age. If 
a child is already in attendance at a Day Nursery, admission to 
a Nursery School may be deferred until it reaches the age of 
three years. The Board anticipate that for the present at all 


events, children will usually leave the Nursery School at the 
age of five, or more conveniently at the end of the term in which 
they attain that age. So long as five years remains the age at 
which compulsory attendance at school begins in an area, the 
transfer of children from a Nursery School at a later age would 
retard their progress and disturb the organisation of the Public 
Elementary School. Moreover, while the accommodation in 
Nursery Schools is limited, as it is likely to be for some time, the 
interests of the younger children should as a rule take precedence 
of the interests of children between the age of five and six. In 
exceptional circumstances, however, it will no doubt be desired 
to retain children over the age of five. Before assenting under 
Article 1 (&) to such retention the Board will require to be 
satisfied (1) that the Local Education Authority concur in the 
arrangement, (2) that the premises and staff are suitable for 
children over the age of five, and (3) that there are sufficient 
grounds for the application, e.g., that the children are delicate 
or require special attention. 

22. Daily Houline. — The usual hours of opening and closing 
the school should be respectively somewhat earlier and later 
than those of the Elementary School, so as to allow elder children 
to bring and fetch their yoimger brothers and sisters. Occupa- 
tions should be both individual and collective. Children should 
be free to develop their own tastes and interests, but should also 
learn to associate with their companions and to control conduct 
likely to annoy others. They should be carefully trained to be 
self-reliant and to serve each other, sharing together in a love 
of persons and things ; and an atmosphere of freedom, happiness, 
and mutual affection should be cultivated. The school should 
provide the child with a joyous experience in all relations, a 
simple, clean, and wholesome environment in which it can grow 
in sociability and naturalness. An essential condition of its 
success will be its homeliness and its retention of the loyalty 
and confidence of the mothers of the children. These conditions 
are intimately related to the health of the children. 

23. Three of the most important physical advantages to 
secure in a Nursery School are : (a) nulriliovrt-good food, fresh 
air, cleanliness, and healthy bodily habits ; (ft) exercise. — by 
abundance of free play and informal exercise, and the avoidance 
of finely-adjusted movemcnta ; (c) rest — by requiring periods of 
rest in the horizontal attitude, by short and varied lessons, and 
by suitable chain and apparatus, the use of which prevents 
strain or restleesnefls. The purpose of the school is not to 
UiocM " the three Rs," but by sleep, food and play, to provide 
the opportunity for little children to lay the foundations of 
licaltii, good habit, and a responsive and receptive personality. 


Children should be bathed at least once a week. Heads 

should be combed regularly. The washing of heads, the cleansing 
of teeth, and the use of the oflSces must be closely supervised. 
The children should be trained in cleanly habits, but encouraged 
to assist themselves as far as possible. 

27. Until further experience has been obtained, the Board do 
not think it desirable to attempt to prescribe a precise scale of 
staffing for Nursery Schools. They would expect, however, that 
a Nursery School containing 40-50 children would require the 
services of a superintendent, an experienced assistant, and a 
probationer. The number suggested would appear to be the 
minimum, regard having been had to the special care and atten- 
tion that it will be necessary to give to children for whom Nursery 
Schools will be provided. In larger schools additional assistance 
would obviously be required. 

28. Finally, it is a matter of the first importance to facilitate 
the free interchange of teachers between Nursery Schools and 
other schools ; the creation of a separate caste of Nursery School 
teachers would be a matter of regret in the mterests of the 
teaching profession. The Board have no doubt that Local 
Education Authorities and Managers will bear this in mind when 
considering the staffing of Nursery Schools, and will encourage 
persons in their emploj^ment to obtain, if they do not already 
possess, qualifications for work in elementary and other schools 
and departments for younger children. 

29. The Relation of Nursery Schools fo other Institutions. — It 
has hitherto been assumed for purposes of convenient description 
that the Nursery School or class will be a separate institution. 
Proposals may, however, be submitted for the recognition of 
Nursery Schools or classes which form a part of other organisations. 
It may, for instance, be desired to establish a Nursery School in 
the same premises as a Day Nursery or an Infant Department 
of a Public Elementary School. The considerations already 
mentioned would apply generally to any such proposal with 
any modifications required by the circumstances of each case. 
In the case of association Avith a Day Nursery, for instance, 
where the premises would be largely used in common, special 
importance would attach to the selection of a suitable person as 
Superintendent who could take charge of the whole Institution. 
The Board would be unwilling to recognise a Nursery School 
attached to a Day Nursery unless there were at least 20 children 
of two years old and upwards. 

3l8t December 1918. 




1. Day Nurseries are intended primarily to provide for the 
care of healthy infants and young children whose mothers are 
obhged to engage in daily work which takes them away from 
their own homes or who are temporarily in distress ; when cir- 
cumstances permit, the Nurseries should also be available for 
the needs of mothers who, for domestic or other reasons, are 
temporarily imable to provide satisfactory care for their little 
children in their OAvn homes, or with suitable relatives or friends, 
or with good foster-mothers. It is not intended to encourage 
the estabUshment or maintenance of Day Nurseries for children 
who do not come within any of the above categories. 

2. Day Nurseries are most suitable for children under three 
years of age who majnly require special physical care and 
attention. Infants under nine months should not as a rule be 
admitted, unless it is shown that their mothers for good and 
sufficient reason are obliged to work or are unable to continue 
breast-feeding. Even when some hand-feeding is necessary 
partial breast-feeding should always be encouraged. Children 
over three years of age should attend a Nursery School instead 
of the Day Nursery whenever this is possible. If it is essential 
for them to remain at the Day Nursery, every endeavour should 
be made to provide for training in good liabits and personal 
hygiene, and to accustom the children to help themselves and 
one another as much as practicable. When there are fifteen or 
more children over three in regular attendance at a Day Nursery, 
a teacher having kindergarten or nursery school experience 
should be engaged. Careful inquiries should be made into the 
home conditions of children who are admitted, with a view to 
ascertaining the reasons for admission to the Nursery, and the 
nature of the care available for the child in its own liome. No 
child should be refused admission solely on grounds of illegitimacy. 
The number of children in a Day Nursery should nonnally be 
30 to 35, though in exceptional circumstances as many as 50 
might be accommodated. 

3. A Day Nursery may be established and maintained either 
by a local authority or by a voluntary body; many of those 
maintained by voluntary bodies receive financial assistance from 
the local authority; this tends to secure close oo-opcration 


between the local authority and the voluntary body, which is 
essential to the complete success of a general scheme for Maternity 
and Child Welfare. Whether the institution is maintained by 
the local authority or by a voluntary body, it is eminently 
desirable that it should have a Managing Committee containing 
voluntary workers and including working women. Their 
assistance, both on the Committee and in the practical work of 
the institution, creates an atmosphere of human sympathy and 
friendship which is eminently desirable. The value of dis- 
interested work of this kind is immeasurable. But voluntary 
helpers will only be of use if they are competent, attend regularly, 
and have definite duties allotted to them. 

4. The Ministry are aware that it is impracticable to require 
uniform conditions at all Nurseries, but they consider that a 
minimum standard of efficiency must be secured, and the fol- 
lowing points should be borne in mind in the organisation and 
conduct of a Nursery : — 

(a) Provision should be made for the medical supervision of 
all infants and young children on admission to the Nursery, 
and for their examination when necessary. The Medical 
Officer should be suitably remunerated, and should be ap- 
pointed to visit the Nursery at frequent intervals. His or her 
services should also be available at other times in case of 
emergency. The frequency with which individual children 
should be examined by the Medical Officer will depend on 
the state of their health. The Medical Officer should be 
responsible for arrangements for the feeding and physical care 
of the children. Daily watch should also be kept over the 
physical condition of the children in order to deal promptly 
with any case of illness or possible infectious disease. While 
much of this work will necessarily be undertaken by the 
Matron, it should all be subject to the control of the Medical 
Officer, and under the general supervision of the Medical 
Officer of Health. 

(h) It is essential that the Matron should be adequately 
trained. For all new appointments, a woman should be 
selected who has had definite training and experience in the 
care of healthy children, and either full training in a general 
or children's hospital, or such training and experience in 
infantile ailments as will enable her readily to detect the 
first symptoms of infectious disease. She should also have 
had satisfactory experience of work in a Day Nursery. Some 
knowledge of house-keeping is important. A house com- 
mittee to supervise the domestic arrangements is advisable. 
Besides the Matron, at least one person will be required, even 
in^a small Nursery, who is competent to assume responsibility 


in the temporary absence of the Matron. The number of 
probationers or other assistants required will depend on the 
number of children admitted. It will usually be found that 
not less than one nursery-trained assistant in addition to the 
Matron is needed for every 8-10 children under two years of 
age ; a nursery-trained assistant and probationer for 15-20 
children; a nm-sery-trained assistant and two probationers 
for 25 children. Domestic assistance will also be required. 

(c) Adequate provision should be made for the suitable feeding 
of the infants and young children attending the Nursery. 
The food provided should be appropriate to the varying needs 
of the children ; this is of special importance where the child 
is suflFering from malnutrition. Separate diet sheets should 
be kept for infants under 12 months and for older children. 
There should be a daily record of the dinner actually given. 

(d) If any child attending a Day Nursery is found to be in- 
sufficiently nourished, arrangements should be made to secure 
that it is supplied with sufficient pure milk and with such other 
foods as the Medical Officer prescribes for it, not only during 
the time of its attendance at the Nursery, but also while it is 
at home. Local authorities are empowered, with the sanction 
of the Ministry, to supply mUk and other food to children 
under five either at cost price, or, where the parents cannot 
afford to pay full cost, at such price as they can afford. Most 
authorities carrying out Maternity and Child Welfare Schemes 
have arranged for a supply of milk for children under five, 
and any child attending a Day Nursery who is found to be 
insufficiently nourished at home should be referred to the 
Health Visitor or to the Medical Officer of Health of the 
district, who should take such steps as may be necessary to 
rectify any errors or neglect. The actual distribution of the 
milk can often be convem'ently arranged through the Nursery. 

(e) Since a large amount of sleep is essential to the well-being 
and progress of children of tliis age, adequate opportunities 
should be afforded the children for sleeping under healthy 
conditions. They should be taken into the open air as much 
as possible. Attention should also be paid to the training of 
the children in the elementary rules of health and conduct. 
The importance of a high standard of cleanUness should not 
be overlooked. The organisation of the children's play will 
require consideration. 

(/) Children of tender ago are speciallv susceptible to measles 
and certain other forms of epidemic ciisease, and the trreatcst 
care must be exercised to prevent the admission to the Nursery 
of any child who is suspected of suffering from any infectious 
or oontagioua disease, and at times the temporary closure of 


the Nursery may be found essential. Every closure of a Nur- 
sery, Avhether for infectious disease or other cause, should be 
reported to the Ministry. Every child should be seen by a 
responsible person daily on arrival. The rules for controlling 
infectious diseases should be approved by the Medical Officer 
of Health. Arrangements should be made to store separately 
and to disinfect the clothes of the children and to provide 
them with special clothes to wear while at the Nursery. From 
time to time the disinfection of the whole premises will be 

(g) As a general rule, all children under two years of age 
should be bathed daily and dressed in Nursery clothes. Chil- 
dren over two should be bathed daily when necessary, and 
in any case two or three times a week. Separate towels, 
flannels, etc., should be provided for all children, and older 
children should be taught the regular use of the tooth-brush, 
(/i) The character of the accommodation required will vary 
with the number and ages of the children admitted, but it 
should normally include (i.) at least two nurseries, one for 
infants and one for young children; (ii.) suitable provision 
for receivmg and bathing the children and for keeping their 
clothes; (iii.) a kitchen and larder ; (iv.) a milk larder and safe, 
and place for the preparation of bottles ; (v.) proper sanitary 
arrangements for the children ; (vi.) adequate provision for 
daily laundry and keeping soiled garments ; (vii.) provision 
for heating water separate from that for cooking ; (viii.) 
accommodation for the staff ; and (ix.) a small isolation room. 
Proper arrangements should be made for safety, and for ready 
evacuation of the premises, in case of fire, and the efficiency 
of these arrangements should be subjected to frequent tests. 
Some space in the open air, where children can play, should be 
provided, and an open-air playground will be required in the 
case of the nurseries seeking recognition in future. The 
Medical Officer of Health of the local authority carrying out 
the Maternity and Child Welfare Scheme for the district should 
be consulted, in the case of a voluntary nursery, as to the 
accommodation to be provided, and the maximum number of 
children to be admitted. Provision should be made for 
mothers who come to nurse their infants, 
(t) Steps should be taken by home visiting or other means to 
secure that only those children are admitted for whom adequate 
care cannot be provided in their home by reason of the 
unavoidable absence of the mother. The necessary home 
visiting may be done by the Health Visitor of the district, 
who should be in close touch with the Day Nursery. Day 
Nxirseried ought not to provide for children whose mothers 


might reasonably be expected themselves to bestow on them 
the necessary care and attention. 

(j) Accurate records, including a register of attendance, must 
always be kept. The records kept by the Nursery should 
include information as to the home circumstances of the 
child, and the grounds on which it was considered suitable 
for admission. A note should be kept of the extent to which 
the cliildren attending the Nursery have suffered from measles 
or other forms of epidemic disease. All infants under one 
year should be weighed weekly, and the weights recorded. 
Older chUdren should be weighed from time to time and a 
note made of their progress, together with observations of 
the Medical Officer on their physical condition. Records 
should be placed at the disposal of the School Medical Officer 
when the child is of age to enter school. 

(k) In some cases it may be possible for a Day Nursery to 
retain a certain number of children by night as well as by day 
for a short period, as a temporary measure, when this is made 
necessary by the illness of the mother or some similar reason. 
Such children should not usually be retained for more than 
one or two weeks, and the period of residence should not 
exceed a month unless the circumstances are exceptional. 
There should be no attempt to utiUse Day Nurseries as 
residential institutions. Special approval of the Ministry is 
required for the admission of resident children, and will only 
be given if suitable night nurseries are available and if there 
are adequate facilities for play and exercise in the open air. 
Separate records should be kept of all resident children, stating 
the reason for admission as residents and the period of stay. 
(I) In some districts Homes have been established for children 
under five whose parents are temporarily unable to keep them 

f>roperly at their own homes, and such institutions may be 
ound more suitable than a Day Nursery for the retention of 
such children. Neither a home for children nor a resident 
Day Nursery should be regarded as affording a satisfactory 
permanent homo for children under live, who should be 
brought up in circumstances approximating as closely as 
pcesible to home and family life. 

(m) Where two or more Nurseries exist in the same neighbour- 
hood, the areas which they serve should be defined, or other 
stops taken to prevent overlapping. Close co-operation is 
desirable with institutions dealing with Infant Welfare in the 
neighbourhood. Infant Welfare Centres will often be able 
to supply information as to suitable cases for admission to 
the Nursery, and the Nursery may also in di£[oi*ent ways be 
able to afford useful assistance to the Centres. Where a 


Treatment Centre or Infant Dispensary exists, arrangements 
may advantageously be made for that institution to deal 
with cases requiring specific medical or surgical treatment. 
No child who is definitely ill should be admitted to a Day 
Nursery. Children suffering from malnutrition or simple 
non-infective ailments may be admitted temporarily, but if 
after a period of observation their condition does not improve 
they should, if possible, be transferred to a hospital. Hospitals 
for ailing children have been established in manj?^ districts, 
and arrangements might be made through the Medical Officer 
of Health for the admission of aiHng children into these pending 
their sufficient recovery for acceptance in the Nursery. 

Ministry of Health, 
Whitehall, S.W.I, 
November 1919. 



County Council op Durham. 


At the last meeting of the County Maternity and Ctiild Welfare 
Committee, I pointed out that many trained midwives under 
existing conditions were vmable to earn a hving wage, and that 
the scheme of the County Council for subsidising trained midwives 
appointed by them does not provide adequate remuneration in 
most cases. By that scheme the Council undertakes under 
certain conditions to pay a subsidy of £30 per annum to an 
approved trained midwife, provided her total income from 
midwifery, including the subsidy, does not exceed £80 per 
annum, the amount of subsidy payable decreasing in proportion 
as the midwifery fees exceed £50, so that as soon as a midwife's 
earnings reach £80 per annum, the subsidy from the County 
Council ceases. Your Committee then instructed me to prepare 
a scheme for securing satisfactory remuneration to approved 
trained midwives. I would point out that since the present 
county midwifery scheme was adopted, the Local Government 
Board has issued an important circular, dated 9th August 1918, 
with regard to the provision of midwives and grants in aid thereof, 
and the position has been further modified by the passing of the 
Midwives Act, 1918, which came into operation on the 1st January 
of this year. The Ixjcal Government Board in their circiilar 
state that it is important that the status of midwives should be 
raiticd, and that com^wttint trained M'omen, who devote them- 
■elves to the servioe should bo adequately remunerated, and that 



a competent trained midwife, devoting her whole time to the 
work, should be able to secure at the present time an income of 
from £120 to £150 a year. 

The Board in their circular also make the following remarks 
which have an important bearing on the matter : — " In cases in 
which a council provide or arrange for a general midwifery 
service, they should fix a scale of fees, but these may be reduced 
or remitted in individual cases, where the circumstances justify 
this course. In so far as the fees received do not meet the cost 
of this service, the Board are prepared, subject to their prior 
approval of any scheme, to find one-half of the deficiency," 
..." In all cases the grant in respect of midwifery will be 
subject to the following conditions: — (1) that the Board are 
satisfied that the midwife is competent, (2) that her services are 
available in respect of aU women who need them, and (3) that 
the ordinary fee of the district is charged, and that it is only 
reduced or remitted where the circumstances of the case justify 
the adoption of this course." 

I need not in this report refer to the present position of the 
midwifery service in the administrative county, as this was 
indicated in my reports to the Council of July 1917, and July 
1918, except to say that it is quite inadequate, and in the interests 
of the mother and infant, urgently needs improvement. 

After careful consideration of the matter I put forward the 
following recommendations : — 

(1) The County Council should guarantee to every approved 
trained midwife devoting her whole time to the work of mid- 
wifery a salary of £120 per annum. 

(2) In addition such midwife to be guaranteed a bonus of 48. 
per case up to 150 cases per annum. This bonus would ensure 
that a midwife attending 150 cases per amium would have a 
total income of £150, and would be an inducement to the 
midwife to increase the number of her patients. 

(3) The midwife, except in'strictly necessitous cases, to charge 
a fee of lOs. 6d. for each confinement, which it will be her 
duty to collect and which will set against the income 
guaranteed by the Council. 

(4) The mid^vife to attend aU women who need her services 
within the area in which she practises. 

(5) The midwife to attend as a maternity nurse under a medical 
practitioner when her services are so required and to charge 
a minimum fee of 58. for such services, the Council's bonus of 
4s. being also payable in respect of each such case. 

(6) The midwife to act under the directions of the County 
Medical Officer and to co-operate with the Maternity and 
Child Welfare Centre of the (Strict in which she practises, so 



far aa the interesta of the mothers and infants under her care 
require it. 

(7) The midwife to be allowed two weeks' holiday each year, 
and to at once report absence from duty owing to illness or 
other cause to the County Medical Officer. 

(8) An agreement embodying the above and any other neces- 
sary conditions to be entered into between the County Council 
and the midwife, renewable annually and determinable at 
any time in case of negUgence, incompetence or misconduct 
on the part of the midwife. 

The consent of the Local Government Board would have to 
be obtained to any such scheme as I have outUned, it being under- 
stood that the Board would pay a grant of 60 per cent, of the 
cost incurred by the County CoimcU. 

With regard to No. 3 of my recommendations, it may be 
reasonably urged that 10s. 6d. is an insufficient fee for the 
services of a trained midwife, and that such fee should be fixed 
at £1, Is. Od. I have given this matter very careful considera- 
tion, and I am inclined to think that in practice the smaller fee, 
having regard to the conditions prevailing in this county, will be 
more satisfactory. If a fee of £1, Is. Od. were charged, I am 
satisfied that many women would refrain from engaging a trained 
midwife, and would continue the present unsatisfactory practice 
of engaging the handywoman to look after her during the 
lying-in period, and relying on the doctor to attend when re- 
quired. Moreover, many untrained midwives are satisfied with 
a fee of lOs. 6d., and if the trained midwife was required to 
charge a considerably higher fee, she would be placed under an 
imfair handicap in competing with these untrained women. 
I^It is possible that there are a few trained midwives in the 
county earning a larger income than they would be likely to 
obtain under the salary and bonus scheme suggested in this 
report, and some of these midwives also charge a higher fee than 
ICte. 6d. In cases where such midwives are likely to be brought 
into competition with women appointed under the county scheme 
this difficulty could be overcome by the Council agreeing to their 
charging the county fee and paying them the difference between 
that fee and the higher fee they had been charging. Any such 
arrangement would, however, be dependent on their complying 
with the other conditions to be observed by the trained midwives 
appointed by the Council. 

With the object of encouraging the trained midwife to give 
the necessary attention to ante- natal conditions, I suggest that 
a small fee of, say, Ss., should be payable by the Council, but 
this fee should only apply to those cases when the midwife has 
been engaged for the confinement at Jeast .three months before 


it is expected, and has complied with other necessary conditions, 
such as co-operation with the Welfare Medical Officer or other 
medical practitioner when medical advice was reqxiired. 

As regards the cost of an adequate trained mid^vifery service 
to cover the whole county, one may estimate the total births 
under normal conditions at 28,000 per annum. Under any 
circumstances, probably not less than 30 per cent, of the births 
will always be attended by medical practitioners. Up to the 
present less than 25 per cent, of the births in this county are 
attended by certified midwives. The practice of midwifery by 
the untrained certified midwives is annually decreasing, but it 
will probably be some years before 50 per cent, of the births are 
attended by trained midwives. On the basis, however, of 50 
per cent, of the births being attended by trained women, this 
would represent 14,000 births annually which would necessitate 
the employment of the full-time services of approximately 100 
trained midwives. 

At the present time less than 60 trained midwives are prac- 
tising in the administrative county, and the majority of these are 
not earning an adequate income. The cost to the Council of 
100 trained midwives guaranteed a salary and bonus as recom- 
mended in this report would be somewhere about £15,000 per 
annum. Against this would be set the fees earned by these 
midwives, which, assuming each midwife attended 150 cases at 
a fee of 10s. 6d. per case, would reduce the amount by £7875, 
but as many of the midwives would at first not be fully em- 
ployed, the income from the fees would be considerably below 
that sum for the next few years, and probably would not exceed 
£4000 during the first year, though gradually increasing in 
subsequent years. The total fees proposed to be paid to midwives 
for ante-natal work would not be large, probably not exceeding 
£500 per annum, and I am inclined to the opinion that during 
the first three years of the scheme the total cost, after deducting 
the fees received, would be about £11,000 per annum. From 
this would be deducted the grant from the Local Government 
Board estimated at 50 per cent, of the net cost, so that the 
charge on the county rates would be approximately £5500 per 

Under the Midwives Act, 1918, there will be an additional 
charge on the county rates, as the Council are required to pay 
(1) the fees of medical practitioners called in by midwives in any 
emergency ; (2) increased contributions to the expenses of the 
Central Midwives Board ; (3) for all forms and books which 
midwives are required to fill up and use as well as all postages of 
forms, etc., required to be forwarded to the Council. I am 
afraid there is very httle hope that the majority of the fees to 


be paid to medical practitioners called in by midwives will bo 
recoverable from the patients. 

Further, any complete midwifery scheme will impose financial 
obligations in the Council in connection with the provision of 
accommodation in hospitals and lying-in-homes for diseases and 
complications associated with pregnancy both in the mothers 
and infants, as well as provision for a certain number of normal 
cases, such as, for instance, women whose home conditions are 
insanitary or otherwise unsuitable. 

Part of the cost of any scheme for providing " Home Helps " 
would also have to be allocated to the County Midwifery Scheme, 
and it appears to be probable that the net cost to the County of 
a complete scheme would at no distant date total £10,000 per 
annum. Admittedly this is a very large outlay, but I am fully 
satisfied that the saving of life and the prevention of disease 
and suffering which would result would be worth many times 
that sum. 

The relative roles of the County Council and the County 
Nursing Association in providing a County Midwifery Service 
require to be definitely settled. It will be remembered that one 
of the objects of the Association is to assist in the provision of 
a midwifery service for the administrative county, and to some 
extent the County Midwives Committee and the County Maternity 
and Child Welfare Committee agreed that the provision of 
trained midwives should be referred to the County Association. 
I am inclined to think, however, that, having regard to the 
increased powers and responsibilities placed on County Councils 
under the new Midwives Act 'and the regulations of the Local 
Government Board, the Council should not altogether rely on 
the County Nursing Association to train and provide the neces- 
sary midwives, but should proceed with a scheme as suggested 
in this report. The County Council should work in close con- 
junction with the Nursing Association, and should give substan- 
tial financial assistance to aflfiliated District Nursing Associations 
providing nurso-midwivcs on the lines already approved by the 
Council and the Association. Some time must, however, elapse 
before an adequate number of nurse-midwives can be trained 
and provided by the County Association, and moreover some of 
the existing District Nursing Associations are averse from 
employing a midwife sven in districts where one is urgently 
needed. Further, the County Nursing Association has not so 
fully at its disposal expert medical advice which is needed in 
organising a complete county midwifery service, and I recom- 
mend, therefore, that the County Council 'should proceed to 
provide trained midwives in districts needing them 'where such 
provision is not likely to be made in the immediate future by 


the Nursing Association. The Association will, it is to be hoped, 
proceed at once with a scheme for training county midwives 
and a condition might be included in any agreement of service 
between a midwife and the County Council that any such midwife 
should, if required, act as the midwife of a nursing association 
covering the district in which she practises and be responsible to 
that body, subject to the requirements of the Midwives Acts. 

In the event of the County Council deciding to proceed with a 
scheme for providing a trained midwifery service for their area, 
I wish to appeal to the medical profession in the county to give 
it their whole-hearted support, without which it cannot be a 
complete success. Many medical practitioners who during the 
last few years have had an opportunity of judging the work 
accomplished by competent^ trained midwives have expressed 
to me their appreciation of such women who, with very few 
exceptions, may be regarded not as competitors of the doctor, 
but as co-operators, reUeving him of much routine work at in- 
convenient hours. The midwife is required by law to call in 
the doctor on many occasions, and the more competent she is 
the more she will desire his help in difficulty. It is up to the 
doctor to respond with proper spirit, and to assist in promoting 
the welfare of a body of women who work under arduous con- 
ditions, often of considerable responsibility, for a very small 
remuneration. Moreover, the doctor can, if he so desires, put 
a stop to practice by unquahfied women in his district, and thus 
free the competent midwife from a very unfair competitor. A 
condition to be imposed on the midwife would be that in advising 
the calling in of medical aid for a patient, she must in aU cases 
fill in on the requisite form the name of the medical man who is 
the recognised medical attendant of the patient. 

I think it is probable that the payment of the fees on the scale 
laid down by the Local Government Board to doctors called in by 
midwives in emergency cases will lead to an increase in the prac- 
tice of certified midwives, for the doctor wiU reahse that in many 
cases he will obtain a higher fee when called in by a midwife 
than if he was himself engaged for the confinement, and he will, 
therefore, be inclined to refer a larger proportion of cases to the 


County Health Department, 
Shire HaU, Durham, 

14th January 1919. 

Note (Jan. 1920). — At a later meeting the scheme for the 
County Trained Midwifery Service was passed by the County 
Council. At the suggestion of the Medical Officer it was agreed 


that where a whole-time midwife was appointed by a Nm^ing 
Association with the approval of the County Council, any deficit 
incurred should be met by the County Council, provided that the 
same fee for midwifery was charged as under the County scheme. 
Also, in respect of nurse-midwives appointed under similar ap- 
proval, the Council wovild pay a grant of £30 per annum or 10s. 6d. 
a case, whichever were the greater, similar provision being made 
as above in respect of the fee charged. 

The scheme has been approved by the Ministry of Health. 




(Affiliated to the Hertfordshire County Nursing Association.) 

Memobakdum of ak Aqbeement made the 
day of one thousand nine hundred and 

Between of in the 

County of (hereinafter called " the Nurse ") of the 

one part and the Nuksino Association (here- 

inafter called " the Association ") by Secretary 

of the Association of the other part whereby it 

is agreed as follows : — 

The Nttese aoeees with the Assooution. 

1. That she will at all times punctually observe and carry 
out all the Rules and Regulations of the Association for the 
time being in force. 

2. That she will always see that the directions of the medical 
man in charge of the respective cases are carried out, and further, 
that she will be responsible to the Committee for the proper 
nursing and prescribed treatment of every case attended by her. 

3. ^Hiat she will faithfully carry out the duties of Village 
Nurse, Midwife, School Nurse, Tuberculosis Nurse and Health 

4. That she will be responsible to the Committee for all 
apnliances and garment« lent to patients being returned in good 


6. In consideration of the Association taking the Nurse into 
their employment the Nurse agrees that she will not without 
the consent in writing of the Association under the hand of their 
Secretary for a period of five years after she has left the service 
of the Association act as Village Nurse, Tuberculosis Nurse, 
District Nurse, Health Visitor, School Nurse, Midwife, or Mater- 
nity Nurse within the district of or within 
five miles therefrom. 

Thb Association agrees with thb Nubsh. 

1. To give her an annual salary of £ rising by annual 
increments of £ to a maximum salary of £ and an 
allowance of per week for board, lodgings, and laundry, 
and to pay £5 per annum for uniform in accordance with the 
terms set out in the Schedule [see Grade Class ] and to 
pay her travelliag expenses (if any) in connection with her duties 
as Nurse. 

2. To allow her one calendar month's holiday in the year, and 
to be off duty from 2 p.m. on Saturday till 10 a.m. on Monday 
once a month with the exception of the month of hoUday, 
provided the cases allow of her absence. 

3. In the event of illness to allow her for one month her full 
salary, and after the expiration of that time, should the illness 
continue, her case will be considered by the Committee as to 
whether the whole or any part of her salary should be paid for 
any and if so what longer period. She is to receive in addition 
any benefit due to her under the Insurance Act. 

Provided always : 

That if the Nurse is guilty of misconduct or neglect of duty 
she may immediately be suspended by the Chairman or Hon. 
Secretary of the Committee, and the Committee, if satisfied of 
such neglect or misconduct, may summarily dismiss the Nurse, 
and she shall forthwith leave the Association. 

That this engagement may be determined by one calendar 
month's previous notice in writing on either side expiring at 
any time or in the event of misconduct on the part of the Nurse 
at any time without notice. 

As Witness the hands of the said parties hereto 
the day and year above-mentioned. 

Witness to the signature of the above-mentioned. 

Witness to the signature of the above-mentioned. 



Memorandum of a Scheme passed at a Meeting of the General 
County Committee held at 20 Arlington Street on Thursday, 
3rd October 1918, for equalising and putting on an increasing 
scale the salaries of Queen's Nurses, Midwives, and Village 
Nurse-Midwives employed by Associations afliliated to l£e 
County Nursing Association. 

The Nttrses are Divided into Fottr Grades. 
These Grades are again divided in Classes : — 

Grade I. — Village Nurse-Midwives (Three Classes). 

(A) Population under 1000. 

(B) Ditto, over 1000 and under 2000. 

(C) Ditto, over 2000 and under 3000. 

Grade II. — Midwives working in Assooiations em- 
ploying Queen's Nurses. 

(A) Population under 3000. 

(B) Ditto, over 5000. 

Grade III. — Queen's Nurses. 

(A) Population under 3000. 

(B) Ditto, over 3000 and under 5000. 

(C) Ditto, over 5000. 

Grade IV. — The Staff of the Trainino Homi: at 
The Matron and Three Staff Nurses. 

Village Nurse-Midwives. 
Qbadb I. — Class A. — Population undkb 1000. 

Salary — minimum . . £20 rising by annual increment 

of £2, 10s. to— maximum £30 

Board, Lodf^ng and Laun- 
dry Allowance at £1 per 
week . . . 62 52 

Uniform . . . .60 60 

77 87 

War Bonus, £1 per month 12 Tly years' servlc* . 12 

£89 £00 

N.B, — The Nurse under a((reement to County Nursing Association for her 
training to be at the minimum for the first 2| years, and then to reci<iv« 
increment of £7, 10a. 



Gbade I. — Class B. — Population ovbb 1000 and tjndib 2000. 

Salary — minimum 

£25 rising £2, 10s. per annum to 

Board, Lodging and Laundry 

Allowance at £1 per week 52 
Uniform £5 . . .50 

— maximum of 



War Bonus, £1 per month 12 Six years' service 




N.B. — The Nurse under agreement to County Nursing Association to 
start at minimum salary, £20, for first 2 J years, and then to receive incre- 
ment of £10. 

Grade I. — Class C. — Population oveb 2000 and undeb 3000. 

Salarv — minimum 

Board, Lodging, and Laun- 
dry allowance at £1, 3s. per 
week . . . . 59 16 

Uniform . . . .50 

£30 rising by £2, lOs. per annum 

to — maximum 


94 16 

War Bonus, £1 per month 12 Six years' service 
£106 16 

59 16 



£121 16 

N.B. — The Nurse under agreement to County Nursing Association to 
start at minimum salary, £20, for first 2J years, aud then to receive incre- 
ment of £12. 

Midwives working in Associations employing Qneen's Nurses. 

Grade II. — Class A. — Population under 5000. 

Salary — minimum 

Uniform .... 
Allowance of £1, 3s. per 

week for Board, Lodging, 

and Laundry 

£30 rising by annual increment of 
£3 for six years, and one 
year £2 to — maximum . £50 


69 16 
94 16 

War Bonus, £1 per month 12 Seven years' service 
£106 16 

. 69 16 

114 16 
. 12 

£126 16 

N.B. — If more than one Nurse living in the house, the allowance to be 
reduced to £1 per week each. The Nurse under agreement to County Nurs- 
ing Association for her training to start at minimum salary of £20 for first 
2| years, and then to receive increment of £12. 


Ghadb n. — Class B. — Popttlation oveb 6000. 

Salary — ^minimum . . £40 (J 

Uniform , . . .50 
Allowance of £1, 3s. per week 
for Board, Lodging, and 
Washing . . . 59 16 

rising by annual increment 
of £3 for six years, and £2 
for one year . . . £60 

104 16 
War Bonua, £1 per month 12 Seven years' service . 

£116 16 

. 59 16 

124 16 
. 12 

£136 16 

N.B. — If more than one Nurse living in the house, the allowance to be 
reduced to £1 per week each. The Nurse under agreement to County Nurs- 
ing Association to start at minimum salary of £20 for first 2J years, and then 
to receive an increment of £15 first year and £5 second, bringing total to 
£40, after to rise £3 per annum to £60. 

Queen's Nurses. 

Gbade III. — Class A. — Popxjlation under 3000. 

Salary — minimum . . £40 rising by £5 per annum to — 

Allowance for Board, Lodg- maximum , . . £55 

ings, and Laundry, of 

£1, 3s. per week . . 69 16 59 16 

Uniform ....50 50 

104 16 Three years' service . 
War Bonus, £1 per month 12 

£116 16 

119 16 

£131 16 

Gradb in. — Class B. — Population over 3000 and vndbb 5000. 

Salary — minimum 

Allowance for Board, Lodg- 
ings, and Laundry, at 
£1, 3s. per week . 

Unifonn .... 

£45 rising by annual increment 

£5 to — maximum 

59 16 

109 16 Five years' service 
War Bonus, £1 per month 12 

£121 16 


. 69 16 

. 13416 

£146 16 

N.B. — If more than one Nurse living in the house, the allowance to be 
reduced to £1 per week. 


Gbade III. — Class C. — Population oveb 5000. 

Salary — minimum . . £50 rising by £5 per annum to— 
Allowance for Board, liOdg- maximum . . . £80 

ing, and Laundry, at 

£1, 3s. per week . . 59 16 
Uniform .... 5 .... 





114 16 Seven years' service . 
War Bonus, £1 per month 12 

£126 16 £156 16 

N.B. — If more than one Nurse living in the house the allowance to be 
reduced to £1 per week. 

Gbadb IV. — Watpobd Training Homb. 

Matron's Salary — minimum rising by annual increment, 

(All found in Home) . £75 £10 first two years and £5 

after to five years' service £110 
Staff Nurse's Salary . . 50 rising by annual increments 

(AU found) of £5 to , . . 85 

(Seven years' service) 

N.B. — Allowance to be given during holidays for Board and Laundry, 
£1 per week. 

Uniform allowance of £5. 

Pupils' allowance to be 10s. a month. 

1. All Village Nurse-Mid wives while under agreement to the Coimty 
Nursing Association for their training to receive a uniform salary of £20 
and allowances according to scale of Grade and Class and Population in 
which they are employed, i.«., if practising as midwife in a town under an 
Association employing a Queen's Nurse, or acting as Village Nurse-Midwife 
in a single district. At the termination of this 2i years' service the incre- 
ment will vary according to the Grade or Class of Population as set forth in 
the Schedule. 

2. The War Bonus of £1 per month to be given to all Nurses working in 
affiUated Associations from 1st October 1918. Such bonus to remain in 
force for the period of the war and for six months after. 

3. The first annual increment to be given as from April 1919, to all Queen's 
Nurses, Midwives, and Village Nurse-Midwives who are out of agreement 
to the County Nursing Association. 

4. Should a Nurse move from one Association to another in the County 
she should receive salary in accordance with the number of years she has 
served in the County Associalion.and not have to start again at the minimum. 

5. The Nurses will continue to receive their premiums paid on the policies 
under the Pensions Scheme without relation to the increased salaries. 

6. It is suggested that instead of actually giving the Nurses £5 for uniform, 
they should submit the bills for payment by the Committee provided they 
did not exceed £5 in any one year. 

Further, there is a Pension Scheme for Midwives given below 
which makes the salary of greater value. 
The deficit on the workings of certain Associations, whose 


local conditions render it impossible to maintain the nurse- 
midwife there, are paid by the Hertfordshire County Council, in 
order that the provision of midwifery may be assured in those 


At a Meeting of the General County Committee held on 
Thursday, May 10th, 1917, at St. Albans, the following resolution 
was passed unanimously : — 

" That this Committee is in favour of the Scheme for pro- 
viding Pensions for Nurses employed by the County Asso- 
ciation and its Affiliated Associations as submitted to this 

There were 17 representatives of Local Associations present, 
and 13 who were unable to attend had already signified their 
approval of the Scheme by letter. Fourteen other members 
of the County Committee were also present and approved the 
Scheme, and several wrote expressing their regret at being unable 
to come, but giving it their cordial support and sympathy. 

The Scheme suggested to the Meeting was explained by Sir 
Charles Longmore, and is as follows : — 

The Executive Committee have had under consideration a 
Scheme for Pensions for Nurses, suggested to them by the 
County Superintendent ; an extract from her memorandum 
is as follows : — 

(1) "For some years past (even before the war) it has been 
increasingly difficult to obtain Nurses for district work, either 
the full trained Queen's Nurses or the Village Nurse-Midwives. 
What happens is they do the term of years they are bound for 
by agreement and then leave to take up private nursing or to 
obtain posts as health visitors. The average stay of district 
nurses in Hertfordshire during the past ten years has been : 
Queen's Nurses, one year and one month ; Village Nurses two 
years and five months. 

(2) " The salaries of these women are not as good as domestic 
servants, yet they are asked to undertake work that requires 
skill and involves the lives of both mothers and infants, 
entirely relying uj)on their own knowledge as to when it is 
necessary to send for a doctor and being ready to act with 
promptness till ho arrives; this is a heavy responsibility, 
and women so employed should receive adequate pay. The 
minimum salary of a Queen's Nurse is £35, rising to £40 and 
all found, or £100 rising to £105 inclusive. The Village Nurse 
£15 and maximum £25 to £.'{Uf|iii£Z5 to £80 inclusive, when 


out of agreement. I know these salaries are higher than in 
most counties, but the Nurse has to buy her own clothes, boots, 
etc., pay the expenses of a holiday and sundry small items ; 
there can be very little, if any, left to save for her old age. 
Also in many cases I have known the Nurse has a mother or 
some other relative to help. Since the war most of the 
Nurses' salaries have been raised to meet the increased cost 
of Uving, but this does not make them really better off." 

(3) " It is on account of this low pay that the best women do not 
take up the work and also because there is no future in it. 
If they were certain of a pension as in the Post Office, or School 
Teaching Profession, I feel sure women would come forward 
and do the work and stay in their districts." 

(4) " Again, because of the low pay Nurses make little or no 
attempt to save ; but if their emplojmient carried a pension 
they would be encouraged to try and save in order to increase 
that Pension." 

The Committee have gone very carefully into the question, 
and are of opinion that it is desirable in the interests of the 
District Nursing of the future that a Pension in some form should 
be provided for the Nurses in order to maintain the supply, and 
if possible to keep the better and more educated class of women 
practising as midwives. With this end in view, they beg to 
submit the following proposals for the consideration of lyour 
Local Nursing Association's Committee : — 

(1) That all Nurses employed by the County Nursing Associa- 
tion and its Affiliated Associations should have a Pension of 
£15 per annum, payable at 60. The County Association to 
pay half and the Local Associations pay the other half. This 
would mean an annual payment of £3, 9s. 6d. for each Nurse 
for each Local Association. The estimated cost of the whole 
Scheme for the first year is £523, 16s. Od. The County Asso- 
ciation wiU find £261, IBs. Od., and the Local Associations the 
remainder. This is in practical figures an addition of £6, lOs. 
per annum in salary for every Nurse. The sum would, of 
course, vary with the number and ages of the Nurses to be 
insured each year. 

(2) That every Nurse must give one year's satisfactory service 
in the County before a policy is taken out in her name. 

(3) The Pension Scheme to be carried out through the Royal 
National Pensions' Fund for Nurses. The Premiums will be 
paid wholly by the two Committees so long as the Nurse 
works in the County; though the PoUcy will be assigned to 
the Nurse after five years' service, but she wiU not be able 
to obtain the surrender value for a further period of 12 months 
after leaving the County. If she wishes she can continue 


paying the Premium herself. Nurses coming ioto the County 
will be insured at the end of their first year provided they are 
satisfactory and likely to remain. 

(4) The Committee may assign a Nurse her policy or its sur- 
render value before the five years are complete should special 
circumstances render it desirable. 

We appeal to the people of the County to help us to carry out 
this Scheme for the benefit of women who devote their fives to 
work which is of such vital importance to the nation at the 
present time. We know it may be urged this is not the time to 
ask for money for such an object ; but the need is urgent if 
midwives are to be kept at their valuable calling and not leave 
to take up less responsible and more highly paid work elsewhere, 
and the question is one, therefore, which calls for some im- 
mediate action. 

President and Chairman of the Executive Committee. 





OF Health, 1918. 

My object in submitting certain recommendations now rather 
than waiting till a later date is twofold : — 

(1) If what I consider necessary is to be accomphshed, the 
work of getting additional local Parhamentary powers should 
be commenced soon, and 

(2) the Government by their Housing and Town Planning 
BUI of 1919 propose to give to local authorities power to carry 
out schemes under Parts I. and II. of the Act of 1890, which 
schemes may be included with those for which financial 
assistance from the Treasury may be obtained. It is true 
that the wording of the Section of the Act is not very definite, 
but apparently the Government desire that all schemes for 
which this assistance is eligible shall be submitted within a 
short period, and that they shall be carried out witliin three 
years. They have, however, made indefinite provision for 
an extension of time, and it is because of the possibility of 
getting this extension that I think Birmingham ought to be 
able to say quite definitely what the Corporation propose to 
do with the central area of the City, and make an effort now to 
get the scheme for dealing with that area brought within the 
provisions of the Act for financial assistance. 

The steps which have already been taken by Birmingham in 
regard to the housing question may be put very shortly, as 
follows : — 

1. The main, and indeed from a health point of view the 



only, object in our obtaining the great extension of the city in 
1911 was to enable the city to be spread over an area much larger 
than had ever been contemplated previously, and thereby thin 
out the central area. 

2. It was recognised that to enable this to be done properly 
town planning was essential, and the Housing Committee of 
that day contemplated not the restricted town planning as we 
know it now, but town planning of the built-on area of the city, 
as well as the unbuilt-on portions. 

3. It has been pretty generally recognised that housing schemes 
in the central areas of towns have been so expensive in the past 
as to be impracticable as a substantial means of re-housing 

• My present contention is, therefore, that before any attempt 
is made to deal with the central areas it is absolutely essential 
that either by local legislation or by an alteration of the general 
law suitable powers shall be obtained from ParUament to town 
plan the central area. I recognise at once that the proposition 
of dealing with this central area is one of great magnitude 
and one of great cost, and, therefore, reasons must be given 
sufficient to warrant the enormous expenditure that will be 

The only reason which in my judgment calls for this action is 
the improvement of the health of the people. There can be no 
doubt that the conditions under which a large number of the 
people of Birmingham have to live are unwholesome. They 
give rise to ill-health and high mortality ; they give rise to loss 
of self-respect and all that follows such loss of self-respect, viz., 
thriftlessness, drunkenness, dirt, poverty, and crime. 

* The real problem to be dealt with is the question of the back- 
to-back courtyard house, whose chief defect, in addition to its 
lick of size, its dampness, and its dilapidation, is that it is not 
self-contained. There is no water supply inside the dwelling- 
house, no adequate provision for discharging slop water, and 
the only sanitary convenience is often some distance from the 
house and usually common to two or more dwelling-houses. 
This convenience is frequently in a revolting condition, because 
of its common user. There is no bath or moans of having a 
bath in any of the houses. These houses are in many rases 
surrounded by metal or other works giving off smoke and dust, 
so that it is impossible for an occupant to keep himself clean or 
to cultivate any green thing in the neighbourhood of his house. 
The whole outlook from those houses is sullied by soot- besmirched 
buildioffs in a soot-ladon atmosphere. 

It is impoflflible to imagine a rising generation of young people 
being able to improve in health or solf-respeot even if the best 


of educational facilities are provided, when everything they 
come in contact with is sullied by dirtiness and squalor. 

In my opinion there is only one remedy, viz., the re- 

It is often said that you cannot reform the slum dweller. 
This I feel strongly, if accepted, would be a hbel of the worst 
type if applied generally to Birmingham. The majority of people 
in these courtyard houses would be decent, clean people if they 
had a chance of being clean. There is, of course, a small group 
who are thriftless and criminal, but such a group is found in all 
ranks of society. On the whole, therefore, I am quite certain 
that it is safe to spend money freely on our slums, because 
the people will not only benefit enormously in health, but 
they win appreciate the improvement very highly and respond 
to it. 

In 1913 there were 43,366 back-to-back houses in Birming- 
ham, with an estimated population of nearly 200,000 persons 
(a population as large as the whole town of Cardiff or Bolton), 
which may be said to be living under slum conditions. The 
unhealthiness of the dwellers in this type of house is indicated 
graphically in the following maps : — 

Map No. 1 shows in colours the wards in the city of Birming- 
ham where the percentage of houses of the back-to-back type is 
greatest. The darkest area shows where more than 50 per cent, 
of all the dwellings are of the back-to-back type. The second 
darkest colour represents wards having from 20 to 50 per cent, 
of back-to-back houses. The third group shows wards with from 
10 to 20 per cent, of back-to-back houses, and the fourth group 
shows wards with less than 10 per cent, of back-to-back houses. 

Map No. 2 shows the distribution of the death-rate of the city 
during the five years 1914-1918. 

Map No. 3 shows the distribution of infant mortality rates in 
the same five-year period. 

Map No 4 shows the distribution of mortality from Measles. 

Map No. 5 shows the distribution of mortaUty from Bronchitis 
and Pneumonia. 

Map No. 6 shows the distribution of deaths from Phthisis. 

Map No. 7 shows the distribution of deaths from infantile 
summer Diarrhoea. 




Na L 


01—70 p«r joMt 
6^-« . ,. 

I 1 




No. 2. 

TOTAL DEATH-RATE 1914^1918., 

I0-8-2S 8 p«r 1,000. 

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No. 4. 

'■■i-Ai^L,-^A «^s/ J eiiOINCTON SOUTH 

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-^ !^''<*^^^^*••^v:^^l^>2•:<^Jf^•:•:•;•.•■: 






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No. 6. 





No. 0. 

t-ca— e-es p*r ^Si'^^Mi 

I'n— 1-42 „ „ ^^vfeii;^;j 

f03-*-04 „ „ |--v;v:l 

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No 7 


lOIATMl UNDfR a YIAM pen 1.000 ■mTHa.) 

28-«7 pw 1.000 birthi. [«\''A^t''>;it 

10 -3a „ „ 


Many more such maps might be made to show the high in- 
cidence of mortaUty in the central slum areas. Detailed statistics 
have been given in the annual reports on the health of Birming- 
ham for each of the years 1914-1918, and may be consulted for 
confirmation of the general impression given from the maps. 
The more one looks into the subject the more one is impressed 
with the need which exists for a radical change in the conditions 
under which these people are housed. 

The problem of dealing adequately with the slums of Bu-ming- 
ham is, as has already been said, one of even greater magnitude 
and complexity than the very large question of making provision 
for new dwellmgs, which is on hand at the present time. If it 
is agreed that the courtyard back-to-back houses shall be done 
away with, and the remainder of the small house property 
brought up to a fair standard of accommodation and comfort, 
and be made self-contained, then there arises the question which 
I am most anxious should be dealt with almost at once, viz., 
that of the environment of these houses in the central area. 

In my opinion it is impossible to provide clean and bright 
surroundings so long as the present custom exists of permitting 
works to exist alongside of dwellings, and that to merely repLace 
existing houses by new ones would not adequately remedy the 
conditions which we wish to improve. I feel strongly, there- 
fore, that power to town-plan the old area of Birmingham is 
needed, so as to enable the city to be divided into areas somewhat 
on the following lines : — 

I. A Business Centre 

should be defined in which few, if any, restrictions are necessary, 
other than those already existing under the Building Regulations. 

2. Areas in which 

Factories and Workshops 

will have every possible facility which the city can provide, and 
in which no dwelling-house, other than a caretaker's house, shall 
be built without the consent of the Corporation. I believe in 
the past that sufficient attention has not been given to facilitating 
the trade interests of the city, and that it will be greatly to the 
advantage of Birmingham if manufacturers are given facilities 
in the direction of motive power and transit. Birmingham 
largely depends on its metallurgical works. Nearly all these 
works require heating furnaces of various kinds, and each of 
these gives off its quota of soot. I look forward to^the^^tinje 


when a large number of these heating furnaces will be worked 
by cheap varieties of gas rather than coal, and by collecting 
works of this character into groups I think such a supply may be 
possible, while it would be impossible were they scattered. 
Similarly, electricity for power purposes might also be distri- 
buted cheaper in works areas than throughout the whole of the 
town. The selection of these areas need not be so difficult a 
matter as it would appear to be at first sight. They will indicate 
themselves largely by the contour lines and by the existing 
lines of railway and canal. 

It will be noted that no suggestion is made for the compulsory 
removal of works to these areas. I am convinced that it would 
be unwise to attempt any such removal, but I am of opinion that, 
having defined these areas and provided such facilities as I have 
indicated, it will happen in course of time that the residential 
areas will be freed from most of the existing works. 

3. Residential Areas. 

I would suggest that these be defined as areas in which it will 
be illegal for any new works to be built, or any enlargement of 
works to be erected, without the consent of the Corporation. 
I can imagine that in the case of a good many industries which 
produce no smoke or dust or noise little or no objection may 
be raised to their continuing in a residential area if the owner 
so desires. 

The advantage of obtaining such powers before proceeding to 
reconstruct the slum area of Birmingham must be obvious. 
Having defined these areas it will be possible to commence re- 
construction in the areas which are to be permanently residential 
in character, and to do the work in such a way as to secure in 
theee areas pleasant surroundings and the amenities necessary 
for a wholesome life, such as playgrounds, open spaces, tree- 
planted streets, etc. etc. We should then know definitely that 
any expenditure on such areas will bo of permanent value. 

In my opinion the chief feature wliich we must pay attention 
to in obtaining town planning for the old city is this question of 
mapping out areas. Few road alterations need be contem- 
plated, for Birmingham is one of the few large cities without a 
single narrow residential road. The question of main roads need 
not bo dealt with in a town plan, because already these can and 
have boon dealt with. There are, however, a good many areas 
where the building 'sites are unnecessarily deep and may cause 
difficulty. In suoh cases, bowover, there are many methods 
which can be applled,!^uch as providing cross streets or cross 
streets with playgrounds. 


K town planning powers are obtained at an early date to deal 
with the central areas, I think it will be possible to deal with the 
residential portions gradually, and to get some of the work done 
by the owners of the property, who would have a very definite 
assurance that such districts will not be spoiled in the future, 
and that any money expended, will be expended with a knowledge 
that the work being done was part of our definite scheme. Fur- 
ther, I feel that it may be impossible for the city without outside 
fiiiancial help to adequately tackle the very difficult problem of 
reconstructing the central areas, and that if this is to be done 
and the health of the people brought up to the best possible 
state, financial help should be obtained. To obtain this financial 
help it will be necessary to provide a good scheme. We should 
be much more likely to be successful in this respect if we went 
to the Ministry of Health with such a scheme as I am outlining. 

It is obviously premature on my part to discuss the type of 
housing required for these areas. I hope, however, that it will 
not be lower than that foreshadowed in the "Manual" ^ on 
Housing, because what is to be kept in mind is not only the type 
of house which can be lived in by these people, but the kind of 
house which is going, to prevent damage to their health. In 
any existing area there will be some houses which will not require 
to be dealt with, and there will be a good many others which need 
not be pulled down if properly amended. 

I would like to make one further observation in this respect. 
It is that I very strongly advise, that block buildings (flats) 
should not under any con<itions be contemplated as a substitute 
for the back-to-back courtyard houses, as I believejthat such 
in time will become even more unwholesome than the courtyard 

^ Issued by the Local Government Board. 




County Councils and Sanitary Authorities. 

Ministry of Health, 
Whitehall, S.W.I, 

28</i November 1919. 


See. — I am directed by the Minister of Health to state that 
the large numbers of deaths which occur annually from measles, 
and the disabihties and impairment of health which are the 
after-result of this disease in so many cases make it, in the view 
of the Ministry, extremely important that all practical measures 
for combating the mortality from measles should be extended and 
developed as much as possible. 

The Ministry have therefore considered it desirable to review 
the whole position, including the working and results of the 
present notification arrangements which were made obUgatory 
by the Local Government Board Order of 27th November 1915 
(Notification and Treatment of Measles and German Measles). 
The Ministry have given careful consideration to various criti- 
cisms which have reached them as to the ineffectiveness of that 
Order, and have come to the conclusion that its continuance on 
present Unea is not the best method of deahng with the problem. 

A new Order (copies enclosed) has, therefore, been made 
which rescinds the former Order as from 31st December next, 
and I am to request that the rescission of the Regulations may 
be brought to the notice of all medical practitioners and made 
known by every practicable means throughout the district of 
the Authority. In bringing the new Order to the notice of 
local health authorities the Ministry wish it to bo understood 
that it is in no sense their intention to impose any check on the 
action which such authorities can take to combat the mortality 
from measloe. On the contrary, the withdrawal of the Notifi- 
cation Order in ite present form still leaves local authorities free 


to organise various forms of combating and preventing the spread 
of the disease immediately on receiving information respecting 
cases of measles occurring in their districts from the many 
different local sources of information now available. Such in- 
formation should enable appropriate action to be taken not less 
speedily in regard to cases of measles than has been possible when 
knowledge of the incidence of the disease has depended solely 
on notification. 

Section I. — Practical Measures. 

Apart from any information which may in particular localities 
continue to be obtained from some form of notification of 
measles, it is important that the medical officer of health in all 
districts should utilise to the full the various opportunities 
which are available to him to learn of the occurrence of measles 
arising in his district and to follow its epidemic variations. 
This information can be obtained principally through the reports 
of Health Visitors, School Nurses and the School Attendance 
Officer, while parents and guardians should also be encouraged 
to report cases to the office of the Local Sanitary Authority. 

1. Instruction of Parents and Ovardians. — Formal and informal 
lectures by the medical officer of health or medical practitioners 
to those most likely to influence the public attitude to measles ; 
instruction imparted at the Infant Welfare Centre, and other 
propaganda work, such as the distribution of posters, pamphlets, 
etc., on the disease all prove useful in instructing the public 
concerning measles. The practical advice of the health visitor 
or nurse, exempUfied in a particular case in the home, will educate 
the parent and spread practical working knowledge more satis- 
factorily than any other method. 

2. Health Visiting. — It should be a general instruction to 
Health Visitors to whom measles work ia assigned that, on 
learning of the occurrence of a case of measles in their particular 
district, a visit should be made promptly to the home of the 
sufferer. The Health Visitor advises the parents or persons in 
charge as to the infectious nature of the disease and the pre- 
cautions to be taken, and gives elementary instructions as to 
nursing where this is required. She makes inquiries as to the 
existence of previous cases, or of other cases of the disease, 
and as to whether the School Authorities have been informed. 
She reports on her visit to the medical officer of health ; doing 
so immediately, if she finds conditions of environment which 
seem to call for action by the pubhc health authority, or if the 
case is obviously one in which steps should be taken at once to 
secure medical treatment and nursing. If she receives no other 


instructions she continues her visits 'as required until the child 
is convalescent. On receipt of her report, the medical officer 
of health decides whether it is necessary for him to communicate 
with the medical attendant, if any, or to make a personal visit 
to the house, and whether nursing or other assistance is required, 
and in what way it can be supplied. 

4 It is not necessary, as a rule, to appoint Health Visitors solely 
for measles visiting. It is convenient that Health Visitors 
engaged in Maternity and Child Welfare visiting should also 
xmdertake the visiting of cases of measles. In periods of severe 
epidemics of measles it may be necessary for a local authority 
to employ the whole resources of its health visiting staff in 
measles visitiag. In such times of stress, if the staff available 
is insufficient to allow of visits to all cases, such action should be 
confined to children imder five years of age. 

3. Nursing Provision. — This is of the first importance in pre- 
venting mortahty and disablement resulting from measles. The 
services of nurses are not perpetually required, but it is essential 
that sanitary authorities should have a call on the services of 
nurses for home nursing whenever the need for utilisiag them 

Arrangements may be made for engaging the rnu^es of a 
District Nursing Association, or by employing the nurses of the 
sanitary authorities' isolation hospital staff. Often local auth- 
orities of contiguous districts can usefully combine with the object 
of providing nurses who can serve a large number of smaller 
urban districts and rural districts, and who can be dispatched 
to the seat of outbreaks of measles as required. The various 
component authorities combining for this purpose contribute to 
the cost in proportion to their populations or otherwise. Another, 
and in some cases a more efficient and economical arrangement, 
is for the County Council to provide a staff of nurses for the 
visiting and nursing of measles and other infectious diseases, 
such as whooping-cough, poliomyelitis, epidemic diarrhoea and 
ophthalmia neonatorum in children under five years of age 
throughout the county. This provision can be made by County 
Councils exercising their powers under the Maternity and Child 
Welfare Act, 1918. The direct employment of these nurses by 
the County Council for the benefit of the whole administrative 
county simplifies the financial arrangements, since the County 
oan be rated equally for the salaries, and no charge need be 
made for their Bervicee to the particular local authorities who 
tue them. 

With regard to Health Visitors and nurses undertaking visits 
to the homes of cases of measles while engaged also on other 
branches of work, th« Ministry ars advised that subjeot to th« 


taking of simple precautions, on the advice of the medical officer 
of health, there is Uttle or no risk of the conveyance of infection 
from house to house. 

It is, naturally, of the utmost importance that health visitors 
and nurses employed by the local authorities in visiting and 
nursing cases of measles should not only be fully acquainted 
with the principles which govern the work, but should know 
how in practice to make the best of unsatisfactory conditions 
of environment in the interest of the sick child and the family. 

4. Medical Assistance. — The health visitor should be instructed 
to advise the calling in of a doctor in all cases of measles. Med- 
ical assistance may be provided for necessitous cases at the 
expense of the sanitary authority, on the eidvice of the medical 
officer of health. 

6. Institutional Treatment. — Although the majority of cases 
must necessarily be treated at home, yet cases occur where, for 
one or another reason, hospital treatment is specially desirable, 
and provision should be made for such cases. Institutional 
treatment in measles is specially valuable for severe or necessitous 
cases coming from bad home surroundings, whose prospect of 
recovery may be improved by hospital treatment ; and on 
account of the provision made in the institutions for the preven- 
tion of comphcations and sequelae of the disease. 

The Local Government Board in 1911, issued orders enabling 
the managers of the Metropolitan Asylums Board to receive 
patients suffering from measles into their hospitals under certain 
conditions. At present, admission is restricted to very severe 
cases, and to children of the poorest class, who cannot receive 
proper attention at their homes. The cases are recommended 
for admission by medical officers of health and poor law medical 
officers. In certain large urban centres in England and Wales, 
some hospital provision for necessitous cases has been made, but 
the provision is generally inadequate for the needs of the popula- 
tion. In other cases it is entirely lacking. The provision of 
numerous small wards, containing only a few patients, which 
allow of successive cleansing of ea<;h ward, together with prompt 
isolation of a case of bronchial pneumonia, are calculated to 
secure favourable results in hospital treatment. The adoption 
of such measures in France has proved efficacious in checking 
mortality from the disease. 

6. Convalescent Home Treatment. — For children who have 
recently passed through an attack of measles a certain period of 
treatment in a convalescent home is often specially important 
for complete recovery. 

It is desirable, therefore, that local authorities should, either 
themselves or through a voluntary agency, arrajige for beds in 


convalescent homes for children convalescent from measles. 
The selection of suitable cases can be entrusted to the medical 
officer of health. 

7. After-Care. — The health visitor should keep under review 
children who have recently suffered from measles. The disease 
is often followed by a more or less prolonged period of ill-health 
which can be amehorated by good home conditions, suitable 
food, fresh air, and so forth. Special medical observation of 
these cases, e.g., at the Child Welfare Centre, or at a School 
Clinic, seems desirable for some months in order that if sequelae 
arise the child may promptly receive the benefit of expert advice. 

8. Measles in Institutions. — The risks of measles should always 
be kept in mind in connection with day nurseries, creches and 
other institutions for children. The authorities of such institu- 
tions should consult the medical officer of health, or the medical 
officer in attendance at the institution on all cases of suspected 
infectious disease arising in the institution at ordinary times, 
and with regard to all children presenting themselves for ad- 
mission during the prevalence of a measles epidemic. 

Section 2. — Grants for Measles Work. 

In aid of the provision for maternity and child welfare, the 
complete regulations for which are set forth in the Local Gov- 
ernment Board's circular of 9th August 1918 (M. & C. W. 4), 
and the Ministry's circular of 15th July 1919 (Circular No. 6 
M. & C. W. 11), grants not exceeding one- half of approved net 
expenditure are payable by the Ministry during each financial 
year, commencing on Ist April, in respect of the following 
services for measles in the case of children under 5 years of age : — 

(1) The salaries and expenses of Health Visitors engaged in 
Maternity and Child Welfare work (including the home 
visiting of cases of measles). 

(2) Home nursing of cases of measles. 

(3) The provision of hospital beds for measles occurring in 
children under 6 years of age, either permanent or temporary 
in character, provided either at a hospital for infectious 
diseaaee, or in a separate institution. If this provision 
it made at a local authority's hospital for infectious diseases 
it must be arranged so as not to interfere with the accom- 
modation for other infoctioua diseases which are usually 
admitted to hospital. 

(4) The provision of accommodation in convalescent homes 
for children under 6 years of ago. 

It is desirable that Local Authorities should, either themselves 
or through a voluntary agency, arrange for beds in convalescent 


homes to be available for children requiring such treatment after 
measles. As a general rule grants will be paid in the case of 
voluntary agencies providing convalescent homes for this pur- 
pose only in respect of accommodation provided in connection 
with a local authority's scheme and approved by the local 
authority and the Ministry. 

When reason is shown, the Ministry are prepared to consider 
a local Order which would require compulsory notification for 
all cases of measles occurring in the district, not merely the 
first cases, as in the Order of 1915. 
I am. Sir, 

Your obedient Servant, 

To the Toum Clerk or 

The Clerk to the Council. 



Abortifacients — Stopping Traffic in, under Act, 259 
Aldermen — Election for Local Government, 216 
Ante-natal Work 

Birth Notifications, 6, 15 

Breast-feeding see that title 

Centres and Ante-natal Clinics, 44, 140 

Confinements see that title 

Daily Life of Mother, 139 

Dental Care, 66 

Early Engagement of Doctor and Midwife, 139, 140 

Grants in Aid, 141, 142, 144, 145 

Health of Child safeguarded, 137 

Health Visitor see that title 

Home Helps see that title 

Hospital Cases, 144 

Ill-health of Mothers, 138, 145 

Lnportance of Work, Preventive and Curative Aspects, 36, 52, 
53, 137 

Infant Mortality see that title 

Medical Treatment, 53, 78, 139 

Midwives' Work, 36, 52, 53, 105, 139, 172, 290 

Rest Home, 79 

Resulting (jood, 146 

Venereal Disease, 145 

Work involved, 144, 146 

Battersea Milk Depots, 3 
Bennett, Arnold — Five Towns, 200 

County Borough Area Extension, 199 

Housing and Sanitary Conditions in Relation to Mortality 
Rates, Report, 184, 303-315 
Births, Notification of 

Ante-natal Care, 5, 15, 181 

Centres and Notification of Births Visitor, 40 1 

Odmpulsory, Parliamentary Powers, 1907, 8, 9, 13 

First Effort at Notification, 1889, 9 

Forms and Record Cards, 11, 12, 19 

324 INDEX 

Births, Notification of {continued) — 

Leaflets, 18 

Midwives' Notification, 11-13, 134 

Parents' Duty, 11 

Preservation of Notifications, 11 

Still-Births, 35 
Births, Notification of. Act, 1907 

Administrative Authorities, 210 

Adoption of Act, 10, 13, 209 

Health Visitor's Appointment, 264 

Home Visitation, 4, 39 

Monetary Difficulties, 14 

Passing, 9, 129 

Rural Districts worked by Coimty Councils, 82 

Terms of Act Detailed Procedure, 10-13 
Births, Notification of (Extension Act), 1915 

Administration, 210 

Health Visitor's Appointment, 264 

Local Authorities, 14, 15 

Passing of Act, 13 

Rates on Infant Welfare, 14 

Voluntary Agencies, 14, 15 
Births, Notification of (Extension) Act, 1918 — ^Medical Attendance 

Fees, 155 
Births and Death -Rates 

Accurate Records, Recent, 2 

Ante-natal Work, 5, 15, 181 

Baptism Registers inadequate, 8 

Children over one year Death-Rate, 177, 184 

Compulsory Registration, 8 

Determining Rate of Births by Excess over Deaths, 2 

Durham Birth-Rate, 291 

Fall in Birth-Rate, Causes, 2, 177, 178 

Housing and Sanitary Conditions in Relation to Mortality Rates 
in Birmingham, Report, 303-315 

Inadequacy of Registration up to 1837, 8 

Infant Mortality see that title 

Measles and Death-Rate, Ministry of Health Report, 188, 316-321 

Mother, Care at Confinement, 5 

National Vitality and Rate of Incronso, 2 

Statistics, Rate of Registrar, 176, 177 

Still-Births, 35 
Bosrded-out Children 

Adoption, Legal Power of, 123 

Children Act. 1908, 122 

Cost, Fee offered, 122 

Defective Children, Mental and Pbyoical, Institution Life, 123 

Homoa of Others best, 121 

Institutions for, 121-123 

INDEX 825 

Boarded-out Children (continued) — 

Ministry of Health taking over, 122, 124 

Officers' Children, Ministry of Pensions Regulations, 123 

Supervision, 121, 122 
Bonney, Mr. — Maternal Mortality Report, 187 
Boroughs and County Boroughs 

Administrative Areas for Public Health, etc., 198, 199 

Constitution of County Boroughs, 194, 195, 197 

Creation of County Boroughs, 199, 206 

Duties of County Councils, 211 

Education Authorities, 209 

Local Government Administrative Powers, 206, 207, 212, 214 

Midwives' Inspection, 209, 220 

Sanitary Authorities, 206 
Breast-feeding of Infants 

Care and Trouble necessary, 151 

Diarrhnaa, 183 

Food for Mothers, Effect of, 55, 63, 64 

Importance of, 63, 64, 151 

Instructions on, 139 

Times of Feeds, 152 
Broncho-pneumonia — Infant Mortality, 190, 310 
Budin, Professor 

Consultation des Nourrissons, 3 

Manuel Pratique d' Allaitement, 179 
Bums, Mr. John 

Health Visitors' BiU, 14 

Notification of Births Act, 1907, 9, 10 

Cambridge — County Borougli Application, 199 J 
Cecil, Lord Robert— Notification of Births Act, 1907, 9 
Centres, Child Welfare 

Accommodation required, 44 

Administrative Agencies working, Ministry of Health Statistics, 

Ante-natal Work see that title 

Attendance of Mothers and Children, 34, 47, 83, 84, 85, 262 

Beds attached, 253, 254 

Boarded-out Children Attendance, 122 

Building Grants, 229 

Clothing Supervision, 48-50, 139 

Confuiements see that title 

Day Nurseries see that title 

Dental Clmic, 44, 65-67, 253 

Development of Activities, 42 

Dinners for Mothers, 55, 63, 64 

Domestic Economy Teacher, 51 

Equipment and Adaptation of Premises Grants, 257 

Experimental Work Grants, 257 

326 INDEX 

Centres, Child Welfare {continued) — ' 

Financial Difficulties, 111 

Grants in Aid, 111, 112, 228, 229, 257, see also Midwifery, etc. 
Health Visitors see that title 
Home Helps see that title 
Hygiene see that title 
Infant Mortality see that title 
Local Authorities see that title 
Medical Officer of Health, 20, 110 
Medical Treatment and Advice 

Branches of Work, 69 

Children under School Age, 43, 75-78 

Confinement Cases, 80 

Consultation Centres, 4, 24, 38, 86 

Curative Medicine, 69 

Drugs, the Provision of, 69-72 

Health Visitors see that title 

Maternity Csises see that title 

Measles, After-care, 320 

Medical Attendance, 253 

Nutritional Disturbances, 73 

Observation Wards, 43, 73 

Out-Door Treatment, 72 

Preventive before Curative, 73-76 

Rickety Children, 72 
Midwifery see that title 
Milk Depots, 56, 57 
Number of Centres, 85, 86 
Nursery Schools see that title 
Position of Centres, 85 
Record Cards, 20, 46 

Rural District Work Organisation, 82, 91-100 
School for Mothers Centre, 5, 38, 61 
Small Centres allocated to Districts, 34, 35 
Staff required, 86, 87 
Supervision of Centre, 220, 262 
Talks or Lectures, 50 
Trained Salaried Worker, 111 
Urban Areas, Organisation of Welfare Work, 81-00 
Voluntary Agencies see that title 
Weighing, 45 
Workers' Dross, 45. 
Charitable Agencies see Voluntary Agencies 
Childbirth see Maternity Cases, Ante-natal Work, Confinements 
Children Act, 1908 

Boardod-out Children, 122 

Health Visitors as Infant Protection Viaitons, 261 
Childicn under School Age 

Health Visitors' Supervision, 266 

INDEX 327 

Children under School Age {continued) — 

Hospital Treatment Grants, 245 

lUness among, 230 

Medical Treatment, 75-78 

Nursery Schools see that title 

Teeth affected, 66 
Classes for Mothers — Centre Work, 6, 38, 51 
Cleanliness for Infants — Importance, 163 
Clothing of Children — Supervision necessary, 48-50, 139 
Communism and Individuahsm, 231, 232 
Confinements and Maternity Cases 

Abnormal Conditions, 127 

Ante-natal Treatment, 53, 79, 80, 139, 254 

Charities for the Benefit of Women, 126 

Cleanliness, 153 

Committee appointed under Act, 219, 242, 243 

Doctors' Duties, 78-80, 147, 148, 149 

Feeding of Mothers, 56, 245 

Grants in Aid, 145, 157, 158, 227, 242-262 

Health Visitors, 106, 267 

Home Accommodation, Inadequacy, 164, 165 

Home Help or Handywoman see that title 

Hospital Treatment and Accommodation, 80, 147, 159, 160, 
161, 162, 163, 254 

Infection, Care against, 153 

Labour Period, 148 

Lying-in Homes, 161, 164, 165 

Marriage Certificates of Health, 231 

Maternal Mortality Report, 125, 156, 186, 187 

Maternity Benefit, 157, 158 

Medical Aid called by Midwives, 153-157 

Midwifery see that title 

Ministry of Health Maternity and Child Welfare 1919 Circular, 

Nursing, Importance of, 149, 150, 251, 318 

Nursing Homes, 164 

Ophthalmia Neonatorum, 191 

Poor Law Accommodation, 159, 160 

Puerperal Fever, 191 
Convalescent Homes 

Grants in Aid, 245, 256 

Measles, 191 
Cookery, Health Visitors' Training in, 106 
Councillors— Election for Local Government, 214 
County Boroughs see Borouglis 
County Councils 

Administrative Duties, 196, 197, 208, 210, 211 

Child Welfare Work, 245, 246, /or details see Branches of Work 

Education Authority, 209 

328 INDEX 

County Councils (continued) — 

Elections for Local Government, 215 

Maternity and Child Welfare Committee, 220 

Midwifery see that title 

Notification of Births Act, 1907, 10, 82, 91-100 

Nursing Association see that title 

Public Health Administrative Powers, 196, 197 

Sanitation, Matters dealing with, 93 

For particulars see Branches of Work 
Creches see Day Nurseries 
Cruelty to Children, N.S.P.— Health Visitors, 25 

Day Nurseries or Creches 

Accommodation, 285 

Admittance, 282, 285 

Age of Children, 43, 116 

Beds for Resident Children, 284, 286 

Cleanliness, 285 

Drawbacks and Dangers, 117-120 

Epidemic Diseases, 284 

Feeding, 284 

Gardens or Out-Door Space, 119 

Grants in Aid, 245, 256, 257 

Infection, 117-119 

Local Authority Establishment, 282 

Matron, 283 

Medical Supervision, 283 

Mothers out to Work,' 120 

Object of, 116, 117 

Record Keeping, 286 

Regulations of Ministry of Health, 115, 121, 282-287 

Staff, 284 

Toddlers' Room attached to Centre, 43 

Volimtary Establishment, 282 
Death-Rate see Births and Doath-Rates 
Dental Treatment and Centre Work, 44, 66-67, 263 

Breast-fed Infants, 183 

Centre Cases, 193 

Health Visitor, 193 

Infant Mortality, 182, 312 

Notification of, 193 
Dick, Lawson — Teeth and Rickets, 67 

Confinements see that title 

Fees for Malomity Cases, 154-157, 249 

Hee alno School Children, Centres, eto. 
Dummy Teat, Harinfulnoss, 65 
Durham County Council lioport, 174, 288-294 

INDEX 329 


Expenditure Grants and Disposition of Taxation, 225, 227 

Health Visitors see that title 

Midwifery see that title 
Education Act, 1902 

Local Authorities, 88, 209, 216 

School Children and Medical Inspection see School Children 
Education Act, 1907— Medical Inspection of Schools, 209 
Education Act, 1918 

Nursery Schools Regulations, 115, 270-281 

School Children Medical Inspection, 209 
Elections of Ratepayers for Local Government, 213, 214, 215 
Epidemics see Infectious Diseases 
Eugenic Society — Venereal Diseases, 193 
Experimental Mateniity and Child Welfare Work — Grants ia Aid, 


Feeding of Infants 

Artificially fed Infants and Diarrhoea, 183 

Breast-feeding see that title 

Dietary Troubles, 67, 71 

Grants in Aid, 245, 256 

Milk Depots see that title 

Teeth and Rickets affected by Dietary, 67 
Fildes— Syphihs Report, 192 

Fisher, Hayes — Working Women on Child Welfare Committees, 245 
France — Registration of Births and Death Records, 2, 3 
Future Outlook of Child Welfare, 230-232 


Creches and Infection, 117 
Infant Mortality and Milk, 64 
Registration of Births and Deaths, 2 

Halifax — County Borough Area, 199 . 

Health Visitors and Homo Visitation 

Adoption by Large Districts at first, 39 

Ante-natal Work see that title 

Appointment of Visitors — Regulations, 20, 83, 219, 263 

Boarded-out Children see that title 

Centre Work and Visitation Co-operation, 4, 41, 42, 252, seeaUo 

Committee of Maternity and Child Welfare, 220 

Confinements see that title 

OonsuUalion des Nourrissons, 3 

Cruelty and Neglect, Treatment to be adopted, 25 

Day Nurseries see that title 

Development of Work, 107 

Diarrhoea «ee that title 

880 INDEX 

Health Visitors and Home Visitation (continued) — 
District Areas of Work and Centres, 30, 83, 84, 85 
District Nurses as Health Visitors, 250, 268 
Duties of Health Visitors, 20, 21, 249, 250, 263, 264, 265 
First Efforts, 3, 8 

First Visit of Health Visitor, 17, 106 
Frequency of Visits, 31 
Oouttea de Lait, 3 
Hygiene see that title 

Industrial Economic and Social Conditions, 24 
Infant and School Children Visitor combined, 89 
Infant MortaUty see that title 
Insurance, Trades Unions Clubs, etc., 24 
Interference in Lives of those visited to be avoided, 26 
Local Authorities, 4, 14, 15, etc. 
London Coimty Council General Powers Act, 1908, 14 
Material Aid, 27-29 
Measles see that title 
Medical Advice and Treatment and Consultation with Health 

Visitor, 20, 41, 42, 77, 85 
Mental Deficiency see that title 
Midwifery see that title 
Notification of Births see Births 

Number of Births allocated per Visitor, 16, 32, 33, 83, 84, 93, 249 
Number of Visitors employed, 83, 107 
Nursing by Health Visitors, 251, 266 
Office Work, 33 

Official Health Visitors, 40, 41, 88 
Personahty of Visitor, 107, 108 
Protection of Visitors under Children Act, 1908, 251 
Rcconl Cards and Leaflets, 235-240 
Registration of Birth Co-operation, 9 
Results acliiovcd by Health Visitors, 109 
Right of Entry by Permission only, 18 
Rural Districts County Area Work, 91-100 
Salaries of Visitors, 14, 107 
Sanitary Conditions of Premises, 21, 22 
Sanitary Inspectors, 9, 88, 268 
School Children see that title 
Still-Births Notification, 35 
Time of Visits, 33, 34 
Trained Visitors employed, 40 
Training of Health Visitors 

Curriculum of Study and Work, L.G.B. Regulations, 
106, 107 

Grants in Aid, 14, 263-265 

Hygiene, 101, 102, 104, 106 

Midwifery Training, 37, 101, 105 

Ministry of Health Circular, 1919, 263-269 

INDEX 331 

Health Visitors and Home Visitation (contimted) — 

Training of Health Visitors {cmitinued) — 
Qualifications, 250, 264, 268, 269 
Regulations of L.G.B., 101, 102, 105, 107 
Sanitary Training, 88, 101, 264 
Social Conditions, 104 
Suitable Training, 104, 105 
Technical and Specialised, 102, 103 

Transport for Visitors, 33 

Tuberculosis Work and Health Visitor, 89, 266 

Village Nurse Midwives as Visitors, 98 

Voluntary Agencies see that title 

Work Arrangements and Conditions, 30-37, 89, 90 

Working-CIass Mothers, 108 
Health Visitors' Bill — Rejection, 14 
Hertfordshire County Nursing Association — Scheme for Payments 

and Pensions, 175, 294-302 
Highways — Local Board of Health as Surveyors, 206, 207 
Holland, Dr. Eardley — Ante-natal Work, 145 
Home Help or Handy woman 

Confinements, employing for, 142-144, 149, 255 

Duties, 255 

Grants in Aid, 144, 245, 255 

Scheme for Providing, Cost of, 292 

Training, 255 
Home Life — Married Women at Work, 185 
Homes for Necessitous Children — Grants, 245, 256, 257 

Children's Beds, Grants in Aid, 74, 245, 255, 257, 287 

Infectious Diseases Accommodation, 208 

Maternity Cases, 80, 147, 159, 160, 161, 162, 163, 254 

Measles Beds, 319, 320 

Birmingham Conditions re Mortality Bates, Report, 303-315 

Child Welfare Work, 210 

Diarrhoea caused by Bad Conditions, 182 

Expenditure, Disposition of Taxation, 225 

Grants in Aid, 303 

Infant Mortality, 183, 184 

Local Authorities' Powers under Housing and Town Planning 
Bill, 1919, 209, 210, 303 

Maternity Cases, 165 

Sanitary Authorities' Administration, 210 

Tuberculosis Work, 210 
Huddersfield — Notification of Births compulsory, 9 

Community and Individual Interdependence, 231 

Health Visitors' Training, 103, 106, 254 

Infant Hygiene, 22-24 

882 INDEX 

Infant Mortality 

Age Direction of Movement, 75 

Ailments and Diseases, 183 

Ante-natal Work, 181, see also heading Ante-natal Work 

Bronchitis and Pneumonia, 190 

Causes of Death Statistics, 6, 179, 180 

Centres, Consultations, 179 

Childbirth's Deaths, 125 

Conditions of the Poor, 185, 186 

Curative Measures, 6, 7 

Decrease Ratio, 1, 2, 177, 178, 180, 181 

Diarrhoea Causation, 182, 193 

Housing and Sanitary Conditions re Mortality — Birmingham 
Report, 303-315 

Ignorance and Carelessness, 185 

Married Women's Work, 185 

Measles and German Measles, 188, 316-321 

Midwifery, 181 g 

Milk Depot, Effect of, 179 

Need and Response, 3 

Philanthropic Notices, 2 

Preventive Work of Movement, 6 

Reduction of Mortality, Societies for the, 176 

Respiratory Diseases, 183 

Rural Districts' Percentage, 181 

Sanitary Conditions, 182, 183, 303-315 

Statistics, 176, 177, 230 

Tubercle, 189 

Venereal Diseases, 192, 193 

Whooping-cough, 188, 190 

See aUo Births and Death -Rates 
Infectious Diseases 

Health Visitors' Training, 106 

Measles see that title 

Mortality Rate of Children One to Five Years, 184 


Importance to Child Welfare, If 
Sanitary Authorities' Control, 208 

Nursery Schools' Regulations, 110, 274 

Nursing Aid by Local Authorities, 189 
Insurance Acts 

Health Visitors* Information, 24 

Maternity Cases and Ante-natal lU-hcalth, 138 
Tuberculosis Visitation, 89 J 

Jewesses — Venereal Diseases, 192 
Jostices of the Peace 

Appointment and Powers, History of, 203 

OurUiled Powers, 207, 208 

INDEX 333 

Justices of the Peace (continued) — 
Licensing, 203, 205 
Poor Law Administration, 203, 204, 207 

BJaowledge necessary for Reliable Information, 7 

Lambeth Milk Depots, 3 

Lectures to Mothers, Value of, 50 

Leicester Milk Depots, 3 

Licensing and Justices of the Peace, 203, 205 


Maternity Cases, Medical Attendance Fees, 155 

Milk Depots, 3 
Local Authorities 

Birmingham Housing and Sanitary Conditions re Mortality, 

Child Welfare Centre Work, 4, 81, 112, 113, 114, 251, 252 

Committees of Administration, 215-221 

Durham County Council Report for Midwifery Service, 288-294 

Education Committees' Powers, 209 

Elections by Votes of Ratepayers for Administration of Looal 
Government, 214, 215 


Exchequer Grant, 228 

Government Audit and Supervisions, 14, 226 
Interdependent Locally and Centrally, 227 
Sources of Money for L.G, Purposes, 222-229 

Government Inspectors, 227, 228 

Health Insurance Act and Tuberculosis Work, 210 

Hertfordshire County Nursing Association Report, 294-302 

Home Visitation, 4, 14, 15, etc. 

Maternity Hospitals, 163 

Maternity and Child Welfare Act, 1918, Grants in Aid, 242-262 

Mental Deficiency Act, 210 

Midwifery see that title 

Notification of Births Acts,1907-I5,Admini8tration,10,88,209,210 

Nursing for Epidemic Diseases, 189 

Public Health Administration L.G.B. Areas, 194, 201 

Rates, Estimates, and Levelling Procedure, 218 

Schemes to be submitted to Government Department, 227 

Standing Orders, 218 
Local Government Act, 1888 

Contributions to Local Authorities, 224 

Justices' and Counties' Administrative Powers, 207, 208 
Local Government Act, 1894 — Highways Boards, 207 
Local Government Board 

Administrative Area 

Admmistrative County, 194, 195 
County and Municipal Boroughs, 194-201 

884 INDEX 

Local Government Board (continued) — 
Administrative Area {continued) — 

Development, Powers, and Duties, 202-213 

Geographical Counties, 194, 195 

London, County and City of, Areas, 196 /- 

Parishes, 195 

Poor Law Areas, 201 

Rates, County, 208 

Rural Districts, 195, 196 

Sanitary Areas, Division and Working, 82 

Urban Areas, 82-87, 195, 196 

See also Local Authorities 
Child Mortality Report, 184 

Finance, Sources of Money, for L.G. Purposes, 222-229 
Health Visitors' Regulations, 83, 101, 102, 106, 263 
Infant Mortality Report, 180 
Maternal Mortality Report, 1914-15, 156, 187 
Maternity and Child Welfare Act, 1918, Grants in Aid, 242- 

262, 320 
Maternity Cases, Medical Attendance, 156 
Maternity Hospitals, Report on, 161 
Measles Notification and Treatment Order, 1915, 1919, 188, 

Midwifery see that title 
Notification of Births Act, 1907, 10 
Nursing for Epidemic Diseases, 189, 190 
Sanitation Reports, 182, 183 

Self-Govemment Tendencies distinct from Central Govern- 
ment, 203 
Syphilis Report, 192 

Home Visitation, Voluntary Agencies, 42 
Local Government Powers, 212 
Maternity Cases, Hospital Treatment, 161-163 
Sanitary Authorities, 212 
School Children Ailments Report, 241 
School for Mothers, St. Pancras, 39 
London County Council General Powers Act, 1908 — Health Visitors, 

14, 263 
Luton — County Borough Application, 199 
Lying-in Homos 

Accommodation, Maternity Bods, 80, 147, 161, 264 
Grants in Aid, 246 

ManchcKtor — Maternity Cases and Medical Attendance Fees, 166 
Manchester and Salford Ladies' Health Society — Pioneer Agenoy 

in Child Welfare Work, 8 
Married Women's Work and Infant Mortality, 120, 186 
Biarylebone — Infant Consultation Centre, 1906, 39 

INDEX 335 

Maternity Act, 1915 — Committee of Administration, 219 
Maternity and Child Welfare Act, 1918 

Committee of Administration, 83, 210, 217, 219 

Dinners for Mothers, 56 

Financing Maternity and Child Welfare Committee, 220 

Hospital Beds for Children, 74 

Nursing for Measles, Provision, 318 

Provisions of Act and Administration, 242-262 
Maternity Cases see heading Confinements and Maternity Cases 
Mayors — Borough Council Elections, 215 
Measles and German Measles 

Convalescent Homes, 191, 319 

Grants in Aid for Measles Work, 189, 190, 318, 320, 321 

Health Visitors, 317, 318 

Institutional Treatment, 319 

Medical Assistance, 319 

Ministry of Health Report, 1919, 316-321 

Mortality for, 188, 309 

Notification compulsory, 90, 188, 316-321 

Nursing, 189, 190, 318 
Medical Inspection of Schools see School Children 
Medical Officer of Health see Births, Health Visitors, Midwifery, etc. 
Medical Training Schools 

Maternity Beds, 160 

Midwifery Hospital Training, 161, 162 
Mellanby, Mrs.— Dietary and Teeth, 66, 67 
Mental Deficiency Act, 1913 

Administrative Authority, 210 

Home Visitation, 89, 267 
Metropolitan Boroughs 

Health Visitors, 14 

Notification of Births Act, 1907, 1909, 13 

Voluntary Agencies for Welfare Work, 81 

Ante-natal Work see that title 

Breach of Rules, 135 

Centres Work in connection with, 44, 80, 140 

Clerical Work, 171 

Confinements, Attendance, and Advice, 6, 17, 53, 79, 147, 148, 
150, 267 

Fees, 150, 157, 171, 172, 173 

Grants in Aid, 171, 172, 173, 174, 175, 247, 288-294, 294-302 

Improved Arrangements urgently needed, 231 

Infant Mortality see that title 

Inspection of, 90, 97, 98, 128, 129, 131, 132, 133, 134, 209, 220, 
247, 267 

Lying-in Homes, Accommodation, 161 

Medical Attendance Fees of Doctors called by Midwives, 

886 INDEX 

Midwifery (continued) — 

Medical Students' Training, 136, 160, 161 

Municipal Midwives, 173 

Notification of Births see Biiths, Notification 

Notification of Infection, 90, 132, 191 

Nurse-Midwives, 94-99, 251, 252, 293, 294, 296, 297 

Pension Scheme, 300-302 

Practising Midwives, 130, 167, 168, 169, 170, 171 

Professional Etiquette and Consideration for Midwives, 141 

Provision of Midwives, Insufiicient Number, 167 

Public Health Committees' Duties and Powers, 219 

Raising Standard of Work, 134 

Record Cards and Leaflets, 235-240 

Roll of Central Midwives Board, 128, 130, 168, 169, 170 

Rules of Central Midwives Board, 128, 129 

Shortage of Midwives, 171 


Health Visitors' Training, 37, 105 

Ignorance and Need of Instruction, 131 

Capabilities of Midwives, 157 

Certificate of Central Midwives Board, 103 

Compulsory Training, 126, 127, 128 

Grants in Aid, 175 

Hospital Training, 162 

Hygiene, Need for, 103 

Improved Training, 105 

Length of Time, 135 

Local Government Board Circular, 1918, 288, 289 

Obstetrical Society Examinations 127 

Scholarships of County Councils, 171 

Voluntary Training, 127 
Unregistered Practice, 134, 135 
Untrained Midwives, 128, 130, 131 
Midwives Act, 1902 

Central Midwives Board, 128 
Local Authorities' Powers, 209, 219, 129 
Training of Midwives, 126 
Midwives Act, 1918 
Act, 288-294 
Books for Records, 132 
Grants in Aid, 288 

Inspection of Midwives by Small Districts rescinded, 209 
Local Authorities' Inspection, 129 
Unregistered Midwives, 134, 135 
Milk Depots 

Disadvantages of, 57, 68 
Dried Milk, 68. 69, 62, 63 
Oerms in Milk. 60, 61 
Pasteurised Milk, 67-62 

INDEX 887 

Milk Depots {contimied) — 

Provision of Milk, 3, 56-62, 64 

Sterilisation, 60 
Ministry of Health 

Elections of Ratepayers for Local Government, 214, 215 

For Particulars see Details of Work, i.e. Centres, Midwifery, etc. 
Ministry of Pensions' Regulations re Boarding out Officers' 

Children, 123 
Mortality see Infant Mortality 

Municipal Corporation Act, 1836 — Administration, 204, 206, 

National Health Insurance 

Charges connected with, Claims, 225 

Grants in Aid, 227 

Maternity Benefit Act, 1911, 157 

Tuberculosis Work Act, 1911, 210 
Newman, Sir George — Report of M.O. Board of Education, 78 
Nottingham — County Borough Area, 199 
Nursery Schools 

Age of Admission and Learning, 116, 279 

Aims of, 271 

Dailv Routine, 116, 280, 281 

Gardens and Out-of-Door Accommodation, 272 

Grants in Aid, 115,270 

Hygiene, Physical Care of Children, 271-275 

Infection, 116, 274 

Institutions in Relation to, 281 

Medical Supervision and Inspection, 272, 273 

Mental Training, 275-278 

Premises and Site and Equipment, 278, 279 

Regulations, 116, 270-281 

Social Training, 275-278 

Staff, 281 
Nursing Associations 

Administration, Superintendent of County Associations, 94, 96, 

Affiliation of District Association to County Association, 96 

County Nursing Association, 95 

Difficulties, 95 

District Nursing Association, 95 

Financial Position, 95, 96 

Health Visitors see that title 

Inauguration of Associations, 94 

Midwifery see that title 

Pension Scheme, 300-302 

Queen Victoria Jubilee Institute of Nurses, 98, 296-298 

Scholarships of Coimty Councils, 171 

Training, 97 


338 INDEX 

Nnrslng Aseociations (continued) — 

Welfare Work subsidised for by County Councils, 96-100 

Work and Influence, 100 
Nursling, The, translated by Maloney, 179 

Obstetrical Society of London — Examination for Midwives, 127 
Obstetrics, Report on Teaching of, 136 
Ohio, Cleveland — Welfare Centres and Consultations, 86 
Ophthalmia Neonatorum 

Notifiable Disease, 191 

Treatment, 192 
Overcrowding — Infant Mortality, 184, 303-315, see also Housing 

Parish Councils Act, 1894 — Establishment of " Councils" or " Meet- 
ing," 208, 212 
Parliamentary Elections — Overseers, 213 
Pearson, Prof. Karl — Infant Mortality, 178 
Physiology — Health Visitors' Elementary Study, 106 
Pioneers of Child Welfare Movement, 1, 8 
Police Force 

Justices of the Peace responsible, 203 

Local Authorities' Administration, 216 
Poor Law 

Abolition and Increase of Powers of Local Authorities, 68, 124 

Administrative Areas, 201 

Boarded-out Children, 121 

Elizabethan Poor Law, 207 

Justices of the Peace as Administrators, 203, 204 

Maternity Cases 

Confinements, Provision of Beds, 159, 160, 163 
Medical Attendance Fees, 154 

Overseers' Appointment, 204 

Poor- Rate, beginning of Local Taxation, 203 

Rates Assessment, 223 

" Unions " of Parishes, 207 

Vaccination Acts, 213 
Pre-natal Work see Ante-natal 

Pritchard, Dr. Eric — Infant Consultation Centres, 39 
Privy Council — Central Midwives Board, 128 
Public Health Act, 1848— Central Board of Health, 206 
Public Health Act, 1858— Local Bodies' Powers, 206 
Public Health Acts, 1872, 1875 

Enlargement and Consolidation of Boroughs and Urban DiB> 
tricts, 206 

Local Sanitary Areas, 207 

Nursing for Epidemic Diseases, 189 
Publio Health Department 

Material Aid, 27 

For Work gee Particular Branch of Work 
Puerperal Fever — Notifiable Disease, 191 

INDEX 889 


Assessment of, Basis of Valuation, 222, 223, 224 

Borough or General Rate, 223 

County Rate, 208 

Levelling through Overseers, 213 

Poor Law Assessment, 223 

Property of Boroughs, 223 
Record Cards and Leaflets, 46, 235-240 

Registration of Births and Deaths see Births and Death-Rates 
Revue Internationale de la Croix Rouge — Infant Mortality and 

Milk, 64 
Rickets, Teeth affected by, 66, 67 

Robertson, Dr. — Insanitary Areas and Infant Mortality, 184 
Royal Society of Medicine — Gynaecological Lecture, 187 
Rural Districts 

Administrative Areas for Public Health, etc., 198 

Births Notification, Compulsory Measures, 13 

Centres of Welfare, County Council Work, 82, 91-100 

Elections for Local Government, 215 

Health Visitors see that title 

Infant Mortality, Diarrhoea, 183 

Midwives see Midwifery 

Parish Councils or " Meetings," 208 

Sanitary Powers, 212 

St. Helen's— Milk Depot, 3 
St. Pancras — School for Mothers' Centre, 39 
Saleeby, Dr. — Venereal Disease, 193 
Salford— Notification of Births, 1889, 9 
Sanitary Authorities and Sanitation 

Administrative Powers, 208 

Birmingham Sanitary Conditions re Mortality Rates, 303-305 

Diarrhoea caused by Bad Sanitation, 182 

Housing and Town Plaiming Act, 209-210 

Infant Mortality, 182, 183, 184 

Infectious Diseases Notification Control, 208 


Health Visitors, 21, 22, 101, 268 
Legal Right of Entry, 18 
Training, 9, 103 

Local Government Board Reports, 183 

Local Sanitary Areas and Duties, 200, 206, 207, 211, 212 

Maternity and Child Welfare, 245 
School Children, Medical Inspection 

Ailments Report in London Elementary Schools, 241 

Commencement of Work, 6, 230 

Dental Treatment, 66, 67 

Educatior Authorities' Power, 89 

Health Visitors' Instructions and Practice in School Clinics, 106 

340 INDEX 

School Children, Medical Inspection (continued) — 

Ill-health among, 76, 230 

Infectious Diseases see that title, cdso Measles 

Local Authorities' Duties, 76, 209 

Ministry of Health responsible, 78 

Need for Supervision, 5 

Nursery Schools see that title 

Nursing Associations as Health Visitors, 97 

Record Cards, 19, 20, 47 

Tuberculosis Visiting, 89, 90 
School for Mothers 

Belgium, 3 

Consultations for Infants co-ordinate with, 4, 5 

Starting, 38, 39 
Sheffield — County Borough Area, 199 
Social Work — Health Visitors' Training, 106 
Still-Births — Notifications, 35 
Stoke-on Trent — County Borough Area, 200 
Switzerland — Infant Mortality and Milk, 64 
Syphilis — Infant Mortality, 192 


Disposition of Taxation and Contributions to Local Govern- 
ment, 224-229 

Government Supervision and Responsibility, 226 

Poor Law of Elizabeth, 203 
Times, The— M.i\k for Children, 64 

Aldermen, Election of, 205 

Burgesses' Government, 204 

Charters, Granting of, 203 

Councillors, Election of, 205 

Highways Surveyors, Local Board of Health, 206 

" Local Boards' " Administration, 204, 205 

Municipal Corporation Act, 1835, Administration, 204, 206 

Public Health Acts, 206 

Town Councils' Powers of Administration, 205, 

See also Boroughs and County Boroughs 
Treasury, The 

Child Welfare— Grants in Aid, 228, 245 

Local Government Grants in Aid, 224-229 

Parliamentary Sanction to Estimates, 225, 226 

Source of Money Supply, Disposition of Taxation, 226-229 

Grants in Aid, 227 

Health Visitors, 89, 90, 106, 266 

Insurance Act, 1911, and Local Authorities, 89, 210 

Mortality from, 311 

Nursing Associations subsidiaed as Visitors, 97 

INDEX 341 

Unmarried Mothers and their Children — State Supervision, 158 
Urban Districts 

Administrative Areas for Public Health, etc., 198 

Elections for Local Government, 215 

Local Government Powers, 212 

Poor Law Administration, 207 

Sanitary Powers, 212 

Vaccination Acts — Poor Law Administration, 213 
Venereal Disease 

Grants in Aid, 227 

Infant Mortality, 192, 193 

Maternity Cases, 145 

Royal Commission Report, 193 
Voluntary Agencies 

Advantages of and Disadvantages, 112, 113 


Help of Voluntary Workers, 251, 266 

Local Authorities' Co-operation, 4, 67, 68, 111, 113, 114 

Opening and Working of Centres, 81, 110-114 

Grants, 258 

Health Visitors, 14, 17, 27-29, 39, 40, 42, 110, 251 

Pioneers of Public Work, 114 

Waller, Dr. — Bad Teeth in Nursing Mothers, Lancet, 65, 66 

War and Infant Birth- and Death-Rate, 178 

Warwickshire — Notification of Biiihs Act, 1907, and County 

Council, 11 
Weighing at Centres, 45 
Whooping-cough — Infant Mortality, 188, 190 
Worcestershire — Notification of Births Act, 1907, and County 

Council, 11 





No. I. Just Published. Crown Svo. 6s. net. 





This book, which is the first of a series dealing with social 
questions, is intended to be not only a general introduc- 
tion to the subject of social service, but to deal more 
particularly with the social worker. It aims at providing 
those who are contemplating participation in social work 
of some kind with a general sketch of the opportunities 
of service that present themselves. These will be dealt 
with in more detail in subsequent volumes. It is also an 
attempt to show what are the qualifications and training 
desirable in the social worker. 

This series is issued by Messrs. Bell in conjunction with 
the Ratan Tata Department of Social Science and Admin- 
istration (University of London), but the opinions expressed 
in each volume are those of the authors, and must not be 
taken as committing the Department generally to them. 

First Opinions of the Press are quoted overleaf. 





The Times says : 

"By a clear and logical arrangement of subject it manages to 
combine the function of a manual of information with that of a short 
general treatise on social work, and fulfils well the four aims of the 
series — to show what has been done in the past, to describe what is 
being done now, to discuss problems, and to describe methods. . . . 
The book is a singularly thoughtful and instructive study of a subject 
in which a widely interested public really needs well-considered 
guidance. " 

The Westminster Gazette says : 

" It seems to me perfectly to fulfil the purpose for which it is written, 
namely, while outlining the series to give that information to the would- 
be social worker that he most needs. . . . The powers and organisa- 
tion of local authorities are clearly and well stated, while there is an 
interesting chapter on Settlements and their Future. " 

The Manchester Guardian says : 

"A very useful volume. An immense amount of information, useful 
to social workers of various types, is collected and is so arranged as to 
bring out those general principles which are most likely to be fruitful 
in the developments which we may expect in the near future. 


Further volumes of the Social Service Library at present 
arranged for are: — 

The Boy. By Rev. R. R. Hyde. 

The Mother and the Infant. By Miss E. Y. Eckiiard. 

The Girl. By Miss C. K. Dewar. 

The Worker and the State. By Prof. Frank Tii.lyard. 

York House, Portugal Street, London, W.C. 2. 


HU Forber, Janet Elizabeth 

713 (Lane-Claypon), lady 

F67 The child luelfare movement